Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

CT Maxillofacial w/o Contrast

Facility

$4,667.00

Service Code	HCPCS 70486
Hospital Charge Code	1168186
Hospital Revenue Code	351
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$4,526.99
Rate for Payer: AlohaCare Medicaid	$2,333.50
Rate for Payer: AlohaCare Medicare	$2,333.50
Rate for Payer: Cash Price	$3,033.55
Rate for Payer: Cash Price	$3,033.55
Rate for Payer: Devoted Health Medicare	$2,566.85
Rate for Payer: Hawaii Medical Service Association ABD	$155.53
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2,333.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$169.03
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$3,966.95
Rate for Payer: Humana Medicare	$2,333.50
Rate for Payer: Kaiser Permanente Commercial	$4,200.30
Rate for Payer: Kaiser Permanente Medicaid	$2,380.17
Rate for Payer: Kaiser Permanente Medicare	$2,333.50
Rate for Payer: MDX Hawaii PPO	$4,526.99
Rate for Payer: Ohana Health Plan Medicaid	$2,333.50
Rate for Payer: Ohana Health Plan Medicare	$2,333.50
Rate for Payer: UnitedHealthcare Medicaid	$155.53
Rate for Payer: UnitedHealthcare Medicare	$2,333.50
Rate for Payer: University Health Alliance Commercial	$500.94

CT Maxillofacial w/o Contrast

Facility

$4,667.00

Service Code	HCPCS 70486
Hospital Charge Code	1168186
Hospital Revenue Code	351
Min. Negotiated Rate	$3,966.95
Max. Negotiated Rate	$4,526.99
Rate for Payer: Cash Price	$3,033.55
Rate for Payer: Health Management Network Commercial	$3,966.95
Rate for Payer: Kaiser Permanente Commercial	$4,200.30
Rate for Payer: MDX Hawaii PPO	$4,526.99

CT Maxillofacial w/o Contrast - Report

Professional

Both

$218.00

Service Code	HCPCS 70486 26
Hospital Charge Code	630095
Hospital Revenue Code	972
Min. Negotiated Rate	$40.46
Max. Negotiated Rate	$269.56
Rate for Payer: AlohaCare Medicaid	$87.30
Rate for Payer: AlohaCare Medicare	$40.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$44.51
Rate for Payer: Hawaii Medical Service Association Medicare	$40.46
Rate for Payer: Hawaii Western Management Group Commercial	$269.56
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$44.51
Rate for Payer: Kaiser Permanente Medicaid	$44.51
Rate for Payer: Kaiser Permanente Medicare	$44.51
Rate for Payer: Ohana Health Plan Medicaid	$87.30
Rate for Payer: Ohana Health Plan Medicare	$40.46
Rate for Payer: UnitedHealthcare Medicaid	$87.30
Rate for Payer: UnitedHealthcare Medicare	$40.46

CT Maxillofacial w/ + w/o Contrast

Facility

$1,869.00

Service Code	HCPCS 70488
Hospital Charge Code	1168182
Hospital Revenue Code	351
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 Maxillofacial w/ + w/o Contrast

Facility

$1,869.00

Service Code	HCPCS 70488
Hospital Charge Code	1168182
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
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	$232.90
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$934.50
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	$1,588.65
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	$232.90
Rate for Payer: UnitedHealthcare Medicare	$934.50
Rate for Payer: University Health Alliance Commercial	$804.23

CT Maxillofacial w/ + w/o Contrast - Report

Professional

Both

$257.00

Service Code	HCPCS 70488 26
Hospital Charge Code	630087
Hospital Revenue Code	972
Min. Negotiated Rate	$59.48
Max. Negotiated Rate	$388.55
Rate for Payer: AlohaCare Medicaid	$125.28
Rate for Payer: AlohaCare Medicare	$59.48
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$65.43
Rate for Payer: Hawaii Medical Service Association Medicare	$59.48
Rate for Payer: Hawaii Western Management Group Commercial	$388.55
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$65.43
Rate for Payer: Kaiser Permanente Medicaid	$65.43
Rate for Payer: Kaiser Permanente Medicare	$65.43
Rate for Payer: Ohana Health Plan Medicaid	$125.28
Rate for Payer: Ohana Health Plan Medicare	$59.48
Rate for Payer: UnitedHealthcare Medicaid	$125.28
Rate for Payer: UnitedHealthcare Medicare	$59.48

CT Neck/Chest/Abdomen w/ Contrast

Facility

$5,408.00

Service Code	HCPCS 70491
Hospital Charge Code	8211262
Hospital Revenue Code	351
Min. Negotiated Rate	$4,596.80
Max. Negotiated Rate	$5,245.76
Rate for Payer: Cash Price	$3,515.20
Rate for Payer: Health Management Network Commercial	$4,596.80
Rate for Payer: Kaiser Permanente Commercial	$4,867.20
Rate for Payer: MDX Hawaii PPO	$5,245.76

CT Neck/Chest/Abdomen w/ Contrast

Facility

$5,408.00

Service Code	HCPCS 70491
Hospital Charge Code	8211262
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$5,245.76
Rate for Payer: AlohaCare Medicaid	$2,704.00
Rate for Payer: AlohaCare Medicare	$2,704.00
Rate for Payer: Cash Price	$3,515.20
Rate for Payer: Cash Price	$3,515.20
Rate for Payer: Devoted Health Medicare	$2,974.40
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	$2,704.00
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	$4,596.80
Rate for Payer: Humana Medicare	$2,704.00
Rate for Payer: Kaiser Permanente Commercial	$4,867.20
Rate for Payer: Kaiser Permanente Medicaid	$2,758.08
Rate for Payer: Kaiser Permanente Medicare	$2,704.00
Rate for Payer: MDX Hawaii PPO	$5,245.76
Rate for Payer: Ohana Health Plan Medicaid	$2,704.00
Rate for Payer: Ohana Health Plan Medicare	$2,704.00
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$2,704.00
Rate for Payer: University Health Alliance Commercial	$671.68

CT Neck/Chest/Abdomen w/ Contrast - Report

Professional

Both

$312.00

Service Code	HCPCS 70491 26
Hospital Charge Code	8211264
Hospital Revenue Code	972
Min. Negotiated Rate	$64.67
Max. Negotiated Rate	$323.80
Rate for Payer: AlohaCare Medicaid	$124.95
Rate for Payer: AlohaCare Medicare	$64.67
Rate for Payer: Cash Price	$202.80
Rate for Payer: Cash Price	$202.80
Rate for Payer: Devoted Health Medicare	$71.14
Rate for Payer: Hawaii Medical Service Association Medicare	$64.67
Rate for Payer: Hawaii Western Management Group Commercial	$323.80
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$71.14
Rate for Payer: Kaiser Permanente Medicaid	$71.14
Rate for Payer: Kaiser Permanente Medicare	$71.14
Rate for Payer: Ohana Health Plan Medicaid	$124.95
Rate for Payer: Ohana Health Plan Medicare	$64.67
Rate for Payer: UnitedHealthcare Medicaid	$124.95
Rate for Payer: UnitedHealthcare Medicare	$64.67

CT Neck/Chest/Abdomen w/o Contrast

Facility

$4,657.00

Service Code	HCPCS 70486
Hospital Charge Code	8211265
Hospital Revenue Code	351
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$4,517.29
Rate for Payer: AlohaCare Medicaid	$2,328.50
Rate for Payer: AlohaCare Medicare	$2,328.50
Rate for Payer: Cash Price	$3,027.05
Rate for Payer: Cash Price	$3,027.05
Rate for Payer: Devoted Health Medicare	$2,561.35
Rate for Payer: Hawaii Medical Service Association ABD	$155.53
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2,328.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$169.03
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$3,958.45
Rate for Payer: Humana Medicare	$2,328.50
Rate for Payer: Kaiser Permanente Commercial	$4,191.30
Rate for Payer: Kaiser Permanente Medicaid	$2,375.07
Rate for Payer: Kaiser Permanente Medicare	$2,328.50
Rate for Payer: MDX Hawaii PPO	$4,517.29
Rate for Payer: Ohana Health Plan Medicaid	$2,328.50
Rate for Payer: Ohana Health Plan Medicare	$2,328.50
Rate for Payer: UnitedHealthcare Medicaid	$155.53
Rate for Payer: UnitedHealthcare Medicare	$2,328.50
Rate for Payer: University Health Alliance Commercial	$500.94

CT Neck/Chest/Abdomen w/o Contrast

Facility

$4,657.00

Service Code	HCPCS 70486
Hospital Charge Code	8211265
Hospital Revenue Code	351
Min. Negotiated Rate	$3,958.45
Max. Negotiated Rate	$4,517.29
Rate for Payer: Cash Price	$3,027.05
Rate for Payer: Health Management Network Commercial	$3,958.45
Rate for Payer: Kaiser Permanente Commercial	$4,191.30
Rate for Payer: MDX Hawaii PPO	$4,517.29

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

Professional

Both

$218.00

Service Code	HCPCS 70486 26
Hospital Charge Code	8211267
Hospital Revenue Code	972
Min. Negotiated Rate	$40.46
Max. Negotiated Rate	$269.56
Rate for Payer: AlohaCare Medicaid	$87.30
Rate for Payer: AlohaCare Medicare	$40.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$44.51
Rate for Payer: Hawaii Medical Service Association Medicare	$40.46
Rate for Payer: Hawaii Western Management Group Commercial	$269.56
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$44.51
Rate for Payer: Kaiser Permanente Medicaid	$44.51
Rate for Payer: Kaiser Permanente Medicare	$44.51
Rate for Payer: Ohana Health Plan Medicaid	$87.30
Rate for Payer: Ohana Health Plan Medicare	$40.46
Rate for Payer: UnitedHealthcare Medicaid	$87.30
Rate for Payer: UnitedHealthcare Medicare	$40.46

CT Neck/Chest/Abdomen w/ + w/o Contrast

Facility

$5,798.00

Service Code	HCPCS 70492
Hospital Charge Code	8211259
Hospital Revenue Code	351
Min. Negotiated Rate	$4,928.30
Max. Negotiated Rate	$5,624.06
Rate for Payer: Cash Price	$3,768.70
Rate for Payer: Health Management Network Commercial	$4,928.30
Rate for Payer: Kaiser Permanente Commercial	$5,218.20
Rate for Payer: MDX Hawaii PPO	$5,624.06

CT Neck/Chest/Abdomen w/ + w/o Contrast

Facility

$5,798.00

Service Code	HCPCS 70492
Hospital Charge Code	8211259
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$5,624.06
Rate for Payer: AlohaCare Medicaid	$2,899.00
Rate for Payer: AlohaCare Medicare	$2,899.00
Rate for Payer: Cash Price	$3,768.70
Rate for Payer: Cash Price	$3,768.70
Rate for Payer: Devoted Health Medicare	$3,188.90
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	$2,899.00
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	$4,928.30
Rate for Payer: Humana Medicare	$2,899.00
Rate for Payer: Kaiser Permanente Commercial	$5,218.20
Rate for Payer: Kaiser Permanente Medicaid	$2,956.98
Rate for Payer: Kaiser Permanente Medicare	$2,899.00
Rate for Payer: MDX Hawaii PPO	$5,624.06
Rate for Payer: Ohana Health Plan Medicaid	$2,899.00
Rate for Payer: Ohana Health Plan Medicare	$2,899.00
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$2,899.00
Rate for Payer: University Health Alliance Commercial	$807.15

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

Professional

Both

$375.00

Service Code	HCPCS 70492 26
Hospital Charge Code	8211261
Hospital Revenue Code	972
Min. Negotiated Rate	$75.21
Max. Negotiated Rate	$389.90
Rate for Payer: AlohaCare Medicaid	$150.05
Rate for Payer: AlohaCare Medicare	$75.21
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$82.73
Rate for Payer: Hawaii Medical Service Association Medicare	$75.21
Rate for Payer: Hawaii Western Management Group Commercial	$389.90
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$82.73
Rate for Payer: Kaiser Permanente Medicaid	$82.73
Rate for Payer: Kaiser Permanente Medicare	$82.73
Rate for Payer: Ohana Health Plan Medicaid	$150.05
Rate for Payer: Ohana Health Plan Medicare	$75.21
Rate for Payer: UnitedHealthcare Medicaid	$150.05
Rate for Payer: UnitedHealthcare Medicare	$75.21

CT Neck/Chest/Abd/Pelvis w/ Cont

Facility

$5,408.00

Service Code	HCPCS 70491
Hospital Charge Code	8100907
Hospital Revenue Code	351
Min. Negotiated Rate	$4,596.80
Max. Negotiated Rate	$5,245.76
Rate for Payer: Cash Price	$3,515.20
Rate for Payer: Health Management Network Commercial	$4,596.80
Rate for Payer: Kaiser Permanente Commercial	$4,867.20
Rate for Payer: MDX Hawaii PPO	$5,245.76

CT Neck/Chest/Abd/Pelvis w/ Cont

Facility

$5,408.00

Service Code	HCPCS 70491
Hospital Charge Code	8100907
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$5,245.76
Rate for Payer: AlohaCare Medicaid	$2,704.00
Rate for Payer: AlohaCare Medicare	$2,704.00
Rate for Payer: Cash Price	$3,515.20
Rate for Payer: Cash Price	$3,515.20
Rate for Payer: Devoted Health Medicare	$2,974.40
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	$2,704.00
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	$4,596.80
Rate for Payer: Humana Medicare	$2,704.00
Rate for Payer: Kaiser Permanente Commercial	$4,867.20
Rate for Payer: Kaiser Permanente Medicaid	$2,758.08
Rate for Payer: Kaiser Permanente Medicare	$2,704.00
Rate for Payer: MDX Hawaii PPO	$5,245.76
Rate for Payer: Ohana Health Plan Medicaid	$2,704.00
Rate for Payer: Ohana Health Plan Medicare	$2,704.00
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$2,704.00
Rate for Payer: University Health Alliance Commercial	$671.68

CT Neck/Chest/Abd/Pelvis w/ Cont - Report

Professional

Both

$312.00

Service Code	HCPCS 70491 26
Hospital Charge Code	8100909
Hospital Revenue Code	972
Min. Negotiated Rate	$64.67
Max. Negotiated Rate	$323.80
Rate for Payer: AlohaCare Medicaid	$124.95
Rate for Payer: AlohaCare Medicare	$64.67
Rate for Payer: Cash Price	$202.80
Rate for Payer: Cash Price	$202.80
Rate for Payer: Devoted Health Medicare	$71.14
Rate for Payer: Hawaii Medical Service Association Medicare	$64.67
Rate for Payer: Hawaii Western Management Group Commercial	$323.80
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$71.14
Rate for Payer: Kaiser Permanente Medicaid	$71.14
Rate for Payer: Kaiser Permanente Medicare	$71.14
Rate for Payer: Ohana Health Plan Medicaid	$124.95
Rate for Payer: Ohana Health Plan Medicare	$64.67
Rate for Payer: UnitedHealthcare Medicaid	$124.95
Rate for Payer: UnitedHealthcare Medicare	$64.67

CT Neck/Chest/Abd/Pelvis w/o Cont

Facility

$4,657.00

Service Code	HCPCS 70486
Hospital Charge Code	8211257
Hospital Revenue Code	351
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$4,517.29
Rate for Payer: AlohaCare Medicaid	$2,328.50
Rate for Payer: AlohaCare Medicare	$2,328.50
Rate for Payer: Cash Price	$3,027.05
Rate for Payer: Cash Price	$3,027.05
Rate for Payer: Devoted Health Medicare	$2,561.35
Rate for Payer: Hawaii Medical Service Association ABD	$155.53
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2,328.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$169.03
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$3,958.45
Rate for Payer: Humana Medicare	$2,328.50
Rate for Payer: Kaiser Permanente Commercial	$4,191.30
Rate for Payer: Kaiser Permanente Medicaid	$2,375.07
Rate for Payer: Kaiser Permanente Medicare	$2,328.50
Rate for Payer: MDX Hawaii PPO	$4,517.29
Rate for Payer: Ohana Health Plan Medicaid	$2,328.50
Rate for Payer: Ohana Health Plan Medicare	$2,328.50
Rate for Payer: UnitedHealthcare Medicaid	$155.53
Rate for Payer: UnitedHealthcare Medicare	$2,328.50
Rate for Payer: University Health Alliance Commercial	$500.94

CT Neck/Chest/Abd/Pelvis w/o Cont

Facility

$4,657.00

Service Code	HCPCS 70486
Hospital Charge Code	8211257
Hospital Revenue Code	351
Min. Negotiated Rate	$3,958.45
Max. Negotiated Rate	$4,517.29
Rate for Payer: Cash Price	$3,027.05
Rate for Payer: Health Management Network Commercial	$3,958.45
Rate for Payer: Kaiser Permanente Commercial	$4,191.30
Rate for Payer: MDX Hawaii PPO	$4,517.29

CT Neck/Chest/Abd/Pelvis w/o Cont - Report

Professional

Both

$218.00

Service Code	HCPCS 70486 26
Hospital Charge Code	8211258
Hospital Revenue Code	972
Min. Negotiated Rate	$40.46
Max. Negotiated Rate	$269.56
Rate for Payer: AlohaCare Medicaid	$87.30
Rate for Payer: AlohaCare Medicare	$40.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$44.51
Rate for Payer: Hawaii Medical Service Association Medicare	$40.46
Rate for Payer: Hawaii Western Management Group Commercial	$269.56
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$44.51
Rate for Payer: Kaiser Permanente Medicaid	$44.51
Rate for Payer: Kaiser Permanente Medicare	$44.51
Rate for Payer: Ohana Health Plan Medicaid	$87.30
Rate for Payer: Ohana Health Plan Medicare	$40.46
Rate for Payer: UnitedHealthcare Medicaid	$87.30
Rate for Payer: UnitedHealthcare Medicare	$40.46

CT Neck/Chest/Abd/Pelvis w/ + w/o Cont

Facility

$5,798.00

Service Code	HCPCS 70492
Hospital Charge Code	8100904
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$5,624.06
Rate for Payer: AlohaCare Medicaid	$2,899.00
Rate for Payer: AlohaCare Medicare	$2,899.00
Rate for Payer: Cash Price	$3,768.70
Rate for Payer: Cash Price	$3,768.70
Rate for Payer: Devoted Health Medicare	$3,188.90
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	$2,899.00
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	$4,928.30
Rate for Payer: Humana Medicare	$2,899.00
Rate for Payer: Kaiser Permanente Commercial	$5,218.20
Rate for Payer: Kaiser Permanente Medicaid	$2,956.98
Rate for Payer: Kaiser Permanente Medicare	$2,899.00
Rate for Payer: MDX Hawaii PPO	$5,624.06
Rate for Payer: Ohana Health Plan Medicaid	$2,899.00
Rate for Payer: Ohana Health Plan Medicare	$2,899.00
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$2,899.00
Rate for Payer: University Health Alliance Commercial	$807.15

CT Neck/Chest/Abd/Pelvis w/ + w/o Cont

Facility

$5,798.00

Service Code	HCPCS 70492
Hospital Charge Code	8100904
Hospital Revenue Code	351
Min. Negotiated Rate	$4,928.30
Max. Negotiated Rate	$5,624.06
Rate for Payer: Cash Price	$3,768.70
Rate for Payer: Health Management Network Commercial	$4,928.30
Rate for Payer: Kaiser Permanente Commercial	$5,218.20
Rate for Payer: MDX Hawaii PPO	$5,624.06

CT Neck/Chest/Abd/Pelvis w/ + w/o Cont - Report

Professional

Both

$375.00

Service Code	HCPCS 70492 26
Hospital Charge Code	8100906
Hospital Revenue Code	972
Min. Negotiated Rate	$75.21
Max. Negotiated Rate	$389.90
Rate for Payer: AlohaCare Medicaid	$150.05
Rate for Payer: AlohaCare Medicare	$75.21
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$82.73
Rate for Payer: Hawaii Medical Service Association Medicare	$75.21
Rate for Payer: Hawaii Western Management Group Commercial	$389.90
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$82.73
Rate for Payer: Kaiser Permanente Medicaid	$82.73
Rate for Payer: Kaiser Permanente Medicare	$82.73
Rate for Payer: Ohana Health Plan Medicaid	$150.05
Rate for Payer: Ohana Health Plan Medicare	$75.21
Rate for Payer: UnitedHealthcare Medicaid	$150.05
Rate for Payer: UnitedHealthcare Medicare	$75.21

CT Neck/Chest w/ Contrast

Facility

$5,408.00

Service Code	HCPCS 70491
Hospital Charge Code	8211251
Hospital Revenue Code	351
Min. Negotiated Rate	$4,596.80
Max. Negotiated Rate	$5,245.76
Rate for Payer: Cash Price	$3,515.20
Rate for Payer: Health Management Network Commercial	$4,596.80
Rate for Payer: Kaiser Permanente Commercial	$4,867.20
Rate for Payer: MDX Hawaii PPO	$5,245.76

Know your out-of-pocket cost for care.

All Charges