Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

CT Neck/Chest w/ Contrast

Facility

$5,408.00

Service Code	HCPCS 70491
Hospital Charge Code	8211251
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 w/ Contrast - Report

Professional

Both

$312.00

Service Code	HCPCS 70491 26
Hospital Charge Code	8211253
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 w/o Contrast

Facility

$4,657.00

Service Code	HCPCS 70486
Hospital Charge Code	8211254
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 w/o Contrast

Facility

$4,657.00

Service Code	HCPCS 70486
Hospital Charge Code	8211254
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 w/o Contrast - Report

Professional

Both

$218.00

Service Code	HCPCS 70486 26
Hospital Charge Code	8211256
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 w/ + w/o Contrast

Facility

$5,798.00

Service Code	HCPCS 70492
Hospital Charge Code	8211248
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 w/ + w/o Contrast

Facility

$5,798.00

Service Code	HCPCS 70492
Hospital Charge Code	8211248
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 w/ + w/o Contrast - Report

Professional

Both

$375.00

Service Code	HCPCS 70492 26
Hospital Charge Code	8211250
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 Soft Tissue w/ Contrast

Facility

$2,164.00

Service Code	HCPCS 70491
Hospital Charge Code	1168232
Hospital Revenue Code	351
Min. Negotiated Rate	$1,839.40
Max. Negotiated Rate	$2,099.08
Rate for Payer: Cash Price	$1,406.60
Rate for Payer: Health Management Network Commercial	$1,839.40
Rate for Payer: Kaiser Permanente Commercial	$1,947.60
Rate for Payer: MDX Hawaii PPO	$2,099.08

CT Neck Soft Tissue w/ Contrast

Facility

$2,164.00

Service Code	HCPCS 70491
Hospital Charge Code	1168232
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$2,099.08
Rate for Payer: AlohaCare Medicaid	$1,082.00
Rate for Payer: AlohaCare Medicare	$1,082.00
Rate for Payer: Cash Price	$1,406.60
Rate for Payer: Cash Price	$1,406.60
Rate for Payer: Devoted Health Medicare	$1,190.20
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	$1,082.00
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	$1,839.40
Rate for Payer: Humana Medicare	$1,082.00
Rate for Payer: Kaiser Permanente Commercial	$1,947.60
Rate for Payer: Kaiser Permanente Medicaid	$1,103.64
Rate for Payer: Kaiser Permanente Medicare	$1,082.00
Rate for Payer: MDX Hawaii PPO	$2,099.08
Rate for Payer: Ohana Health Plan Medicaid	$1,082.00
Rate for Payer: Ohana Health Plan Medicare	$1,082.00
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$1,082.00
Rate for Payer: University Health Alliance Commercial	$671.68

CT Neck Soft Tissue w/ Contrast - Report

Professional

Both

$249.00

Service Code	HCPCS 70491 26
Hospital Charge Code	630159
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	$161.85
Rate for Payer: Cash Price	$161.85
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	$211.65
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 Soft Tissue w/o Contrast

Facility

$1,528.00

Service Code	HCPCS 70490
Hospital Charge Code	1168234
Hospital Revenue Code	351
Min. Negotiated Rate	$1,298.80
Max. Negotiated Rate	$1,482.16
Rate for Payer: Cash Price	$993.20
Rate for Payer: Health Management Network Commercial	$1,298.80
Rate for Payer: Kaiser Permanente Commercial	$1,375.20
Rate for Payer: MDX Hawaii PPO	$1,482.16

CT Neck Soft Tissue w/o Contrast

Facility

$1,528.00

Service Code	HCPCS 70490
Hospital Charge Code	1168234
Hospital Revenue Code	351
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$1,482.16
Rate for Payer: AlohaCare Medicaid	$764.00
Rate for Payer: AlohaCare Medicare	$764.00
Rate for Payer: Cash Price	$993.20
Rate for Payer: Cash Price	$993.20
Rate for Payer: Devoted Health Medicare	$840.40
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	$764.00
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	$1,298.80
Rate for Payer: Humana Medicare	$764.00
Rate for Payer: Kaiser Permanente Commercial	$1,375.20
Rate for Payer: Kaiser Permanente Medicaid	$779.28
Rate for Payer: Kaiser Permanente Medicare	$764.00
Rate for Payer: MDX Hawaii PPO	$1,482.16
Rate for Payer: Ohana Health Plan Medicaid	$764.00
Rate for Payer: Ohana Health Plan Medicare	$764.00
Rate for Payer: UnitedHealthcare Medicaid	$155.53
Rate for Payer: UnitedHealthcare Medicare	$764.00
Rate for Payer: University Health Alliance Commercial	$514.61

CT Neck Soft Tissue w/o Contrast - Report

Professional

Both

$233.00

Service Code	HCPCS 70490 26
Hospital Charge Code	630161
Hospital Revenue Code	972
Min. Negotiated Rate	$60.19
Max. Negotiated Rate	$277.62
Rate for Payer: AlohaCare Medicaid	$101.04
Rate for Payer: AlohaCare Medicare	$60.19
Rate for Payer: Cash Price	$151.45
Rate for Payer: Cash Price	$151.45
Rate for Payer: Devoted Health Medicare	$66.21
Rate for Payer: Hawaii Medical Service Association Medicare	$60.19
Rate for Payer: Hawaii Western Management Group Commercial	$277.62
Rate for Payer: Health Management Network Commercial	$198.05
Rate for Payer: Kaiser Permanente Commercial	$66.21
Rate for Payer: Kaiser Permanente Medicaid	$66.21
Rate for Payer: Kaiser Permanente Medicare	$66.21
Rate for Payer: Ohana Health Plan Medicaid	$101.04
Rate for Payer: Ohana Health Plan Medicare	$60.19
Rate for Payer: UnitedHealthcare Medicaid	$101.04
Rate for Payer: UnitedHealthcare Medicare	$60.19

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$2,468.00

Service Code	HCPCS 70492
Hospital Charge Code	1168230
Hospital Revenue Code	351
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	$186.48
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	$253.12
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	$186.48
Rate for Payer: UnitedHealthcare Medicare	$1,234.00
Rate for Payer: University Health Alliance Commercial	$807.15

CT Neck Soft Tissue w/ + w/o Contrast

Facility

$2,468.00

Service Code	HCPCS 70492
Hospital Charge Code	1168230
Hospital Revenue Code	351
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 Neck Soft Tissue w/ + w/o Contrast - Report

Professional

Both

$308.00

Service Code	HCPCS 70492 26
Hospital Charge Code	630155
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	$200.20
Rate for Payer: Cash Price	$200.20
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	$261.80
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 Orbits Sella w/ Contrast

Facility

$2,074.00

Service Code	HCPCS 70481
Hospital Charge Code	1168190
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$2,011.78
Rate for Payer: AlohaCare Medicaid	$1,037.00
Rate for Payer: AlohaCare Medicare	$1,037.00
Rate for Payer: Cash Price	$1,348.10
Rate for Payer: Cash Price	$1,348.10
Rate for Payer: Devoted Health Medicare	$1,140.70
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	$1,037.00
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	$1,762.90
Rate for Payer: Humana Medicare	$1,037.00
Rate for Payer: Kaiser Permanente Commercial	$1,866.60
Rate for Payer: Kaiser Permanente Medicaid	$1,057.74
Rate for Payer: Kaiser Permanente Medicare	$1,037.00
Rate for Payer: MDX Hawaii PPO	$2,011.78
Rate for Payer: Ohana Health Plan Medicaid	$1,037.00
Rate for Payer: Ohana Health Plan Medicare	$1,037.00
Rate for Payer: UnitedHealthcare Medicaid	$186.48
Rate for Payer: UnitedHealthcare Medicare	$1,037.00
Rate for Payer: University Health Alliance Commercial	$702.69

CT Orbits Sella w/ Contrast

Facility

$2,074.00

Service Code	HCPCS 70481
Hospital Charge Code	1168190
Hospital Revenue Code	351
Min. Negotiated Rate	$1,762.90
Max. Negotiated Rate	$2,011.78
Rate for Payer: Cash Price	$1,348.10
Rate for Payer: Health Management Network Commercial	$1,762.90
Rate for Payer: Kaiser Permanente Commercial	$1,866.60
Rate for Payer: MDX Hawaii PPO	$2,011.78

CT Orbits Sella w/ Contrast - Report

Professional

Both

$222.00

Service Code	HCPCS 70481 26
Hospital Charge Code	630103
Hospital Revenue Code	972
Min. Negotiated Rate	$52.91
Max. Negotiated Rate	$323.80
Rate for Payer: AlohaCare Medicaid	$123.29
Rate for Payer: AlohaCare Medicare	$52.91
Rate for Payer: Cash Price	$144.30
Rate for Payer: Cash Price	$144.30
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	$323.80
Rate for Payer: Health Management Network Commercial	$188.70
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	$123.29
Rate for Payer: Ohana Health Plan Medicare	$52.91
Rate for Payer: UnitedHealthcare Medicaid	$123.29
Rate for Payer: UnitedHealthcare Medicare	$52.91

CT Orbits Sella w/o Contrast

Facility

$1,528.00

Service Code	HCPCS 70480
Hospital Charge Code	1168192
Hospital Revenue Code	351
Min. Negotiated Rate	$1,298.80
Max. Negotiated Rate	$1,482.16
Rate for Payer: Cash Price	$993.20
Rate for Payer: Health Management Network Commercial	$1,298.80
Rate for Payer: Kaiser Permanente Commercial	$1,375.20
Rate for Payer: MDX Hawaii PPO	$1,482.16

CT Orbits Sella w/o Contrast

Facility

$1,528.00

Service Code	HCPCS 70480
Hospital Charge Code	1168192
Hospital Revenue Code	351
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$1,482.16
Rate for Payer: AlohaCare Medicaid	$764.00
Rate for Payer: AlohaCare Medicare	$764.00
Rate for Payer: Cash Price	$993.20
Rate for Payer: Cash Price	$993.20
Rate for Payer: Devoted Health Medicare	$840.40
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	$764.00
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	$1,298.80
Rate for Payer: Humana Medicare	$764.00
Rate for Payer: Kaiser Permanente Commercial	$1,375.20
Rate for Payer: Kaiser Permanente Medicaid	$779.28
Rate for Payer: Kaiser Permanente Medicare	$764.00
Rate for Payer: MDX Hawaii PPO	$1,482.16
Rate for Payer: Ohana Health Plan Medicaid	$764.00
Rate for Payer: Ohana Health Plan Medicare	$764.00
Rate for Payer: UnitedHealthcare Medicaid	$155.53
Rate for Payer: UnitedHealthcare Medicare	$764.00
Rate for Payer: University Health Alliance Commercial	$515.48

CT Orbits Sella w/o Contrast - Report

Professional

Both

$233.00

Service Code	HCPCS 70480 26
Hospital Charge Code	630106
Hospital Revenue Code	972
Min. Negotiated Rate	$60.19
Max. Negotiated Rate	$277.62
Rate for Payer: AlohaCare Medicaid	$107.35
Rate for Payer: AlohaCare Medicare	$60.19
Rate for Payer: Cash Price	$151.45
Rate for Payer: Cash Price	$151.45
Rate for Payer: Devoted Health Medicare	$66.21
Rate for Payer: Hawaii Medical Service Association Medicare	$60.19
Rate for Payer: Hawaii Western Management Group Commercial	$277.62
Rate for Payer: Health Management Network Commercial	$198.05
Rate for Payer: Kaiser Permanente Commercial	$66.21
Rate for Payer: Kaiser Permanente Medicaid	$66.21
Rate for Payer: Kaiser Permanente Medicare	$66.21
Rate for Payer: Ohana Health Plan Medicaid	$107.35
Rate for Payer: Ohana Health Plan Medicare	$60.19
Rate for Payer: UnitedHealthcare Medicaid	$107.35
Rate for Payer: UnitedHealthcare Medicare	$60.19

CT Orbits Sella w/ + w/o Contrast

Facility

$2,056.00

Service Code	HCPCS 70482
Hospital Charge Code	1168188
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$1,994.32
Rate for Payer: AlohaCare Medicaid	$1,028.00
Rate for Payer: AlohaCare Medicare	$1,028.00
Rate for Payer: Cash Price	$1,336.40
Rate for Payer: Cash Price	$1,336.40
Rate for Payer: Devoted Health Medicare	$1,130.80
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	$1,028.00
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	$1,747.60
Rate for Payer: Humana Medicare	$1,028.00
Rate for Payer: Kaiser Permanente Commercial	$1,850.40
Rate for Payer: Kaiser Permanente Medicaid	$1,048.56
Rate for Payer: Kaiser Permanente Medicare	$1,028.00
Rate for Payer: MDX Hawaii PPO	$1,994.32
Rate for Payer: Ohana Health Plan Medicaid	$1,028.00
Rate for Payer: Ohana Health Plan Medicare	$1,028.00
Rate for Payer: UnitedHealthcare Medicaid	$232.90
Rate for Payer: UnitedHealthcare Medicare	$1,028.00
Rate for Payer: University Health Alliance Commercial	$807.73

CT Orbits Sella w/ + w/o Contrast

Facility

$2,056.00

Service Code	HCPCS 70482
Hospital Charge Code	1168188
Hospital Revenue Code	351
Min. Negotiated Rate	$1,747.60
Max. Negotiated Rate	$1,994.32
Rate for Payer: Cash Price	$1,336.40
Rate for Payer: Health Management Network Commercial	$1,747.60
Rate for Payer: Kaiser Permanente Commercial	$1,850.40
Rate for Payer: MDX Hawaii PPO	$1,994.32

Know your out-of-pocket cost for care.

All Charges