Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

CT Lower Extremity w/ Contrast Left - Report

Professional

Both

$244.00

Service Code	HCPCS 73701 26,LT
Hospital Charge Code	630069
Hospital Revenue Code	972
Min. Negotiated Rate	$113.33
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$113.33
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Ohana Health Plan Medicaid	$113.33
Rate for Payer: UnitedHealthcare Medicaid	$113.33

CT Lower Extremity w/ Contrast Right

Facility

$1,869.00

Service Code	HCPCS 73701 RT
Hospital Charge Code	1168168
Hospital Revenue Code	352
Min. Negotiated Rate	$194.84
Max. Negotiated Rate	$1,812.93
Rate for Payer: AlohaCare Medicaid	$934.50
Rate for Payer: AlohaCare Medicare	$934.50
Rate for Payer: Cash Price	$1,214.85
Rate for Payer: Cash Price	$1,214.85
Rate for Payer: Devoted Health Medicare	$1,027.95
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Medicare	$934.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$1,775.55
Rate for Payer: Health Management Network Commercial	$1,588.65
Rate for Payer: Humana Medicare	$934.50
Rate for Payer: Kaiser Permanente Commercial	$1,682.10
Rate for Payer: Kaiser Permanente Medicaid	$953.19
Rate for Payer: Kaiser Permanente Medicare	$934.50
Rate for Payer: MDX Hawaii PPO	$1,812.93
Rate for Payer: Ohana Health Plan Medicaid	$934.50
Rate for Payer: Ohana Health Plan Medicare	$934.50
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$934.50
Rate for Payer: University Health Alliance Commercial	$662.37

CT Lower Extremity w/ Contrast Right

Facility

$1,869.00

Service Code	HCPCS 73701 RT
Hospital Charge Code	1168168
Hospital Revenue Code	352
Min. Negotiated Rate	$1,588.65
Max. Negotiated Rate	$1,812.93
Rate for Payer: Cash Price	$1,214.85
Rate for Payer: Health Management Network Commercial	$1,588.65
Rate for Payer: Kaiser Permanente Commercial	$1,682.10
Rate for Payer: MDX Hawaii PPO	$1,812.93

CT Lower Extremity w/ Contrast Right - Report

Professional

Both

$244.00

Service Code	HCPCS 73701 26,RT
Hospital Charge Code	630071
Hospital Revenue Code	972
Min. Negotiated Rate	$113.33
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$113.33
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Ohana Health Plan Medicaid	$113.33
Rate for Payer: UnitedHealthcare Medicaid	$113.33

CT Lower Extremity w/o Contrast Left

Facility

$1,651.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	1168178
Hospital Revenue Code	352
Min. Negotiated Rate	$1,403.35
Max. Negotiated Rate	$1,601.47
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: MDX Hawaii PPO	$1,601.47

CT Lower Extremity w/o Contrast Left

Facility

$1,651.00

Service Code	HCPCS 73700 LT
Hospital Charge Code	1168178
Hospital Revenue Code	352
Min. Negotiated Rate	$163.33
Max. Negotiated Rate	$1,601.47
Rate for Payer: AlohaCare Medicaid	$825.50
Rate for Payer: AlohaCare Medicare	$825.50
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Devoted Health Medicare	$908.05
Rate for Payer: Hawaii Medical Service Association ABD	$163.33
Rate for Payer: Hawaii Medical Service Association Medicare	$825.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$177.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,568.45
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Humana Medicare	$825.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: Kaiser Permanente Medicaid	$842.01
Rate for Payer: Kaiser Permanente Medicare	$825.50
Rate for Payer: MDX Hawaii PPO	$1,601.47
Rate for Payer: Ohana Health Plan Medicaid	$825.50
Rate for Payer: Ohana Health Plan Medicare	$825.50
Rate for Payer: UnitedHealthcare Medicaid	$163.33
Rate for Payer: UnitedHealthcare Medicare	$825.50
Rate for Payer: University Health Alliance Commercial	$497.32

CT Lower Extremity w/o Contrast Left - Report

Professional

Both

$186.00

Service Code	HCPCS 73700 26,LT
Hospital Charge Code	630075
Hospital Revenue Code	972
Min. Negotiated Rate	$87.65
Max. Negotiated Rate	$277.05
Rate for Payer: AlohaCare Medicaid	$87.65
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Hawaii Western Management Group Commercial	$277.05
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Ohana Health Plan Medicaid	$87.65
Rate for Payer: UnitedHealthcare Medicaid	$87.65

CT Lower Extremity w/o Contrast Right

Facility

$1,651.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	1168180
Hospital Revenue Code	352
Min. Negotiated Rate	$1,403.35
Max. Negotiated Rate	$1,601.47
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: MDX Hawaii PPO	$1,601.47

CT Lower Extremity w/o Contrast Right

Facility

$1,651.00

Service Code	HCPCS 73700 RT
Hospital Charge Code	1168180
Hospital Revenue Code	352
Min. Negotiated Rate	$163.33
Max. Negotiated Rate	$1,601.47
Rate for Payer: AlohaCare Medicaid	$825.50
Rate for Payer: AlohaCare Medicare	$825.50
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Devoted Health Medicare	$908.05
Rate for Payer: Hawaii Medical Service Association ABD	$163.33
Rate for Payer: Hawaii Medical Service Association Medicare	$825.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$177.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,568.45
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Humana Medicare	$825.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: Kaiser Permanente Medicaid	$842.01
Rate for Payer: Kaiser Permanente Medicare	$825.50
Rate for Payer: MDX Hawaii PPO	$1,601.47
Rate for Payer: Ohana Health Plan Medicaid	$825.50
Rate for Payer: Ohana Health Plan Medicare	$825.50
Rate for Payer: UnitedHealthcare Medicaid	$163.33
Rate for Payer: UnitedHealthcare Medicare	$825.50
Rate for Payer: University Health Alliance Commercial	$497.32

CT Lower Extremity w/o Contrast Right - Report

Professional

Both

$186.00

Service Code	HCPCS 73700 26,RT
Hospital Charge Code	630079
Hospital Revenue Code	972
Min. Negotiated Rate	$87.65
Max. Negotiated Rate	$277.05
Rate for Payer: AlohaCare Medicaid	$87.65
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Hawaii Western Management Group Commercial	$277.05
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Ohana Health Plan Medicaid	$87.65
Rate for Payer: UnitedHealthcare Medicaid	$87.65

CT Lower Extremity w/+w/o Contrast Bilat

Facility

$2,224.00

Service Code	HCPCS 73702 50
Hospital Charge Code	1168170
Hospital Revenue Code	352
Min. Negotiated Rate	$1,890.40
Max. Negotiated Rate	$2,157.28
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Health Management Network Commercial	$1,890.40
Rate for Payer: Kaiser Permanente Commercial	$2,001.60
Rate for Payer: MDX Hawaii PPO	$2,157.28

CT Lower Extremity w/+w/o Contrast Bilat

Facility

$2,224.00

Service Code	HCPCS 73702 50
Hospital Charge Code	1168170
Hospital Revenue Code	352
Min. Negotiated Rate	$244.38
Max. Negotiated Rate	$2,157.28
Rate for Payer: AlohaCare Medicaid	$1,112.00
Rate for Payer: AlohaCare Medicare	$1,112.00
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Devoted Health Medicare	$1,223.20
Rate for Payer: Hawaii Medical Service Association ABD	$244.38
Rate for Payer: Hawaii Medical Service Association Medicare	$1,112.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$265.57
Rate for Payer: Hawaii Western Management Group Commercial	$2,112.80
Rate for Payer: Health Management Network Commercial	$1,890.40
Rate for Payer: Humana Medicare	$1,112.00
Rate for Payer: Kaiser Permanente Commercial	$2,001.60
Rate for Payer: Kaiser Permanente Medicaid	$1,134.24
Rate for Payer: Kaiser Permanente Medicare	$1,112.00
Rate for Payer: MDX Hawaii PPO	$2,157.28
Rate for Payer: Ohana Health Plan Medicaid	$1,112.00
Rate for Payer: Ohana Health Plan Medicare	$1,112.00
Rate for Payer: UnitedHealthcare Medicaid	$244.38
Rate for Payer: UnitedHealthcare Medicare	$1,112.00
Rate for Payer: University Health Alliance Commercial	$786.23

CT Lower Extremity w/+w/o Contrast Bilat - Report

Professional

Both

$224.00

Service Code	HCPCS 73702 26,LT
Hospital Charge Code	630061
Hospital Revenue Code	972
Min. Negotiated Rate	$133.35
Max. Negotiated Rate	$392.99
Rate for Payer: AlohaCare Medicaid	$133.35
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cash Price	$145.60
Rate for Payer: Hawaii Western Management Group Commercial	$392.99
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Ohana Health Plan Medicaid	$133.35
Rate for Payer: UnitedHealthcare Medicaid	$133.35

CT Lower Extremity w/+w/o Contrast Left

Facility

$2,224.00

Service Code	HCPCS 73702 LT
Hospital Charge Code	1168172
Hospital Revenue Code	352
Min. Negotiated Rate	$244.38
Max. Negotiated Rate	$2,157.28
Rate for Payer: AlohaCare Medicaid	$1,112.00
Rate for Payer: AlohaCare Medicare	$1,112.00
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Devoted Health Medicare	$1,223.20
Rate for Payer: Hawaii Medical Service Association ABD	$244.38
Rate for Payer: Hawaii Medical Service Association Medicare	$1,112.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$265.57
Rate for Payer: Hawaii Western Management Group Commercial	$2,112.80
Rate for Payer: Health Management Network Commercial	$1,890.40
Rate for Payer: Humana Medicare	$1,112.00
Rate for Payer: Kaiser Permanente Commercial	$2,001.60
Rate for Payer: Kaiser Permanente Medicaid	$1,134.24
Rate for Payer: Kaiser Permanente Medicare	$1,112.00
Rate for Payer: MDX Hawaii PPO	$2,157.28
Rate for Payer: Ohana Health Plan Medicaid	$1,112.00
Rate for Payer: Ohana Health Plan Medicare	$1,112.00
Rate for Payer: UnitedHealthcare Medicaid	$244.38
Rate for Payer: UnitedHealthcare Medicare	$1,112.00
Rate for Payer: University Health Alliance Commercial	$786.23

CT Lower Extremity w/+w/o Contrast Left

Facility

$2,224.00

Service Code	HCPCS 73702 LT
Hospital Charge Code	1168172
Hospital Revenue Code	352
Min. Negotiated Rate	$1,890.40
Max. Negotiated Rate	$2,157.28
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Health Management Network Commercial	$1,890.40
Rate for Payer: Kaiser Permanente Commercial	$2,001.60
Rate for Payer: MDX Hawaii PPO	$2,157.28

CT Lower Extremity w/+w/o Contrast Left - Report

Professional

Both

$273.00

Service Code	HCPCS 73702 26,RT
Hospital Charge Code	630063
Hospital Revenue Code	972
Min. Negotiated Rate	$133.35
Max. Negotiated Rate	$392.99
Rate for Payer: AlohaCare Medicaid	$133.35
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
Rate for Payer: Hawaii Western Management Group Commercial	$392.99
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Ohana Health Plan Medicaid	$133.35
Rate for Payer: UnitedHealthcare Medicaid	$133.35

CT Lower Extremity w/+w/o Contrast Right

Facility

$2,224.00

Service Code	HCPCS 73702 RT
Hospital Charge Code	1168174
Hospital Revenue Code	352
Min. Negotiated Rate	$1,890.40
Max. Negotiated Rate	$2,157.28
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Health Management Network Commercial	$1,890.40
Rate for Payer: Kaiser Permanente Commercial	$2,001.60
Rate for Payer: MDX Hawaii PPO	$2,157.28

CT Lower Extremity w/+w/o Contrast Right

Facility

$2,224.00

Service Code	HCPCS 73702 RT
Hospital Charge Code	1168174
Hospital Revenue Code	352
Min. Negotiated Rate	$244.38
Max. Negotiated Rate	$2,157.28
Rate for Payer: AlohaCare Medicaid	$1,112.00
Rate for Payer: AlohaCare Medicare	$1,112.00
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Cash Price	$1,445.60
Rate for Payer: Devoted Health Medicare	$1,223.20
Rate for Payer: Hawaii Medical Service Association ABD	$244.38
Rate for Payer: Hawaii Medical Service Association Medicare	$1,112.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$265.57
Rate for Payer: Hawaii Western Management Group Commercial	$2,112.80
Rate for Payer: Health Management Network Commercial	$1,890.40
Rate for Payer: Humana Medicare	$1,112.00
Rate for Payer: Kaiser Permanente Commercial	$2,001.60
Rate for Payer: Kaiser Permanente Medicaid	$1,134.24
Rate for Payer: Kaiser Permanente Medicare	$1,112.00
Rate for Payer: MDX Hawaii PPO	$2,157.28
Rate for Payer: Ohana Health Plan Medicaid	$1,112.00
Rate for Payer: Ohana Health Plan Medicare	$1,112.00
Rate for Payer: UnitedHealthcare Medicaid	$244.38
Rate for Payer: UnitedHealthcare Medicare	$1,112.00
Rate for Payer: University Health Alliance Commercial	$786.23

CT Lower Extremity w/+w/o Contrast Right - Report

Professional

Both

$273.00

Service Code	HCPCS 73702 26,50
Hospital Charge Code	630065
Hospital Revenue Code	972
Min. Negotiated Rate	$133.35
Max. Negotiated Rate	$392.99
Rate for Payer: AlohaCare Medicaid	$133.35
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
Rate for Payer: Hawaii Western Management Group Commercial	$392.99
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Ohana Health Plan Medicaid	$133.35
Rate for Payer: UnitedHealthcare Medicaid	$133.35

CT Lung Cancer Screening

Facility

$446.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	2424812
Hospital Revenue Code	352
Min. Negotiated Rate	$92.52
Max. Negotiated Rate	$432.62
Rate for Payer: AlohaCare Medicaid	$223.00
Rate for Payer: AlohaCare Medicare	$223.00
Rate for Payer: Cash Price	$289.90
Rate for Payer: Cash Price	$289.90
Rate for Payer: Devoted Health Medicare	$245.30
Rate for Payer: Hawaii Medical Service Association Medicare	$223.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$92.52
Rate for Payer: Hawaii Western Management Group Commercial	$423.70
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Humana Medicare	$223.00
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: Kaiser Permanente Medicaid	$227.46
Rate for Payer: Kaiser Permanente Medicare	$223.00
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: Ohana Health Plan Medicaid	$223.00
Rate for Payer: Ohana Health Plan Medicare	$223.00
Rate for Payer: UnitedHealthcare Medicaid	$92.92
Rate for Payer: UnitedHealthcare Medicare	$223.00
Rate for Payer: University Health Alliance Commercial	$206.29

CT Lung Cancer Screening

Facility

$446.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	2424812
Hospital Revenue Code	352
Min. Negotiated Rate	$379.10
Max. Negotiated Rate	$432.62
Rate for Payer: Cash Price	$289.90
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: MDX Hawaii PPO	$432.62

CT Lung Cancer Screening - Report

Professional

Both

$145.00

Service Code	HCPCS 71271 26
Hospital Charge Code	2424814
Hospital Revenue Code	972
Min. Negotiated Rate	$50.28
Max. Negotiated Rate	$289.63
Rate for Payer: AlohaCare Medicaid	$92.92
Rate for Payer: AlohaCare Medicare	$50.28
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
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	$289.63
Rate for Payer: Health Management Network Commercial	$123.25
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	$92.92
Rate for Payer: Ohana Health Plan Medicare	$50.28
Rate for Payer: UnitedHealthcare Medicaid	$92.92
Rate for Payer: UnitedHealthcare Medicare	$50.28

CT Maxillofacial w/ Contrast

Facility

$1,728.00

Service Code	HCPCS 70487
Hospital Charge Code	1168184
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$1,676.16
Rate for Payer: AlohaCare Medicaid	$864.00
Rate for Payer: AlohaCare Medicare	$864.00
Rate for Payer: Cash Price	$1,123.20
Rate for Payer: Cash Price	$1,123.20
Rate for Payer: Devoted Health Medicare	$950.40
Rate for Payer: Hawaii Medical Service Association ABD	$186.48
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$864.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$202.46
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$1,468.80
Rate for Payer: Humana Medicare	$864.00
Rate for Payer: Kaiser Permanente Commercial	$1,555.20
Rate for Payer: Kaiser Permanente Medicaid	$881.28
Rate for Payer: Kaiser Permanente Medicare	$864.00
Rate for Payer: MDX Hawaii PPO	$1,676.16
Rate for Payer: Ohana Health Plan Medicaid	$864.00
Rate for Payer: Ohana Health Plan Medicare	$864.00
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$864.00
Rate for Payer: University Health Alliance Commercial	$678.04

CT Maxillofacial w/ Contrast

Facility

$1,728.00

Service Code	HCPCS 70487
Hospital Charge Code	1168184
Hospital Revenue Code	351
Min. Negotiated Rate	$1,468.80
Max. Negotiated Rate	$1,676.16
Rate for Payer: Cash Price	$1,123.20
Rate for Payer: Health Management Network Commercial	$1,468.80
Rate for Payer: Kaiser Permanente Commercial	$1,555.20
Rate for Payer: MDX Hawaii PPO	$1,676.16

CT Maxillofacial w/ Contrast - Report

Professional

Both

$244.00

Service Code	HCPCS 70487 26
Hospital Charge Code	630091
Hospital Revenue Code	972
Min. Negotiated Rate	$52.91
Max. Negotiated Rate	$319.59
Rate for Payer: AlohaCare Medicaid	$103.10
Rate for Payer: AlohaCare Medicare	$52.91
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$58.20
Rate for Payer: Hawaii Medical Service Association Medicare	$52.91
Rate for Payer: Hawaii Western Management Group Commercial	$319.59
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$58.20
Rate for Payer: Kaiser Permanente Medicaid	$58.20
Rate for Payer: Kaiser Permanente Medicare	$58.20
Rate for Payer: Ohana Health Plan Medicaid	$103.10
Rate for Payer: Ohana Health Plan Medicare	$52.91
Rate for Payer: UnitedHealthcare Medicaid	$103.10
Rate for Payer: UnitedHealthcare Medicare	$52.91

Know your out-of-pocket cost for care.

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