Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

CT Spine Cervical w/ Contrast

Facility

$2,243.00

Service Code	HCPCS 72126
Hospital Charge Code	1168238
Hospital Revenue Code	352
Min. Negotiated Rate	$232.90
Max. Negotiated Rate	$2,175.71
Rate for Payer: AlohaCare Medicaid	$1,121.50
Rate for Payer: AlohaCare Medicare	$1,121.50
Rate for Payer: Cash Price	$1,457.95
Rate for Payer: Cash Price	$1,457.95
Rate for Payer: Devoted Health Medicare	$1,233.65
Rate for Payer: Hawaii Medical Service Association ABD	$232.90
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$1,121.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$253.12
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,906.55
Rate for Payer: Humana Medicare	$1,121.50
Rate for Payer: Kaiser Permanente Commercial	$2,018.70
Rate for Payer: Kaiser Permanente Medicaid	$1,143.93
Rate for Payer: Kaiser Permanente Medicare	$1,121.50
Rate for Payer: MDX Hawaii PPO	$2,175.71
Rate for Payer: Ohana Health Plan Medicaid	$1,121.50
Rate for Payer: Ohana Health Plan Medicare	$1,121.50
Rate for Payer: UnitedHealthcare Medicaid	$232.90
Rate for Payer: UnitedHealthcare Medicare	$1,121.50
Rate for Payer: University Health Alliance Commercial	$683.96

CT Spine Cervical w/ Contrast

Facility

$2,243.00

Service Code	HCPCS 72126
Hospital Charge Code	1168238
Hospital Revenue Code	352
Min. Negotiated Rate	$1,906.55
Max. Negotiated Rate	$2,175.71
Rate for Payer: Cash Price	$1,457.95
Rate for Payer: Health Management Network Commercial	$1,906.55
Rate for Payer: Kaiser Permanente Commercial	$2,018.70
Rate for Payer: MDX Hawaii PPO	$2,175.71

CT Spine Cervical w/ Contrast - Report

Professional

Both

$386.00

Service Code	HCPCS 72126 26
Hospital Charge Code	629609
Hospital Revenue Code	972
Min. Negotiated Rate	$57.05
Max. Negotiated Rate	$377.25
Rate for Payer: AlohaCare Medicaid	$114.53
Rate for Payer: AlohaCare Medicare	$57.05
Rate for Payer: Cash Price	$250.90
Rate for Payer: Cash Price	$250.90
Rate for Payer: Devoted Health Medicare	$62.76
Rate for Payer: Hawaii Medical Service Association Medicare	$57.05
Rate for Payer: Hawaii Western Management Group Commercial	$377.25
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$62.76
Rate for Payer: Kaiser Permanente Medicaid	$62.76
Rate for Payer: Kaiser Permanente Medicare	$62.76
Rate for Payer: Ohana Health Plan Medicaid	$114.53
Rate for Payer: Ohana Health Plan Medicare	$57.05
Rate for Payer: UnitedHealthcare Medicaid	$114.53
Rate for Payer: UnitedHealthcare Medicare	$57.05

CT Spine Cervical w/o Contrast

Facility

$1,470.00

Service Code	HCPCS 72125
Hospital Charge Code	1168240
Hospital Revenue Code	352
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$1,425.90
Rate for Payer: AlohaCare Medicaid	$735.00
Rate for Payer: AlohaCare Medicare	$735.00
Rate for Payer: Cash Price	$955.50
Rate for Payer: Cash Price	$955.50
Rate for Payer: Devoted Health Medicare	$808.50
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	$735.00
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	$1,249.50
Rate for Payer: Humana Medicare	$735.00
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: Kaiser Permanente Medicaid	$749.70
Rate for Payer: Kaiser Permanente Medicare	$735.00
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: Ohana Health Plan Medicaid	$735.00
Rate for Payer: Ohana Health Plan Medicare	$735.00
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$735.00
Rate for Payer: University Health Alliance Commercial	$502.27

CT Spine Cervical w/o Contrast

Facility

$1,470.00

Service Code	HCPCS 72125
Hospital Charge Code	1168240
Hospital Revenue Code	352
Min. Negotiated Rate	$1,249.50
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$955.50
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: MDX Hawaii PPO	$1,425.90

CT Spine Cervical w/o Contrast - Report

Professional

Both

$186.00

Service Code	HCPCS 72125 26
Hospital Charge Code	629611
Hospital Revenue Code	972
Min. Negotiated Rate	$47.19
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$88.11
Rate for Payer: AlohaCare Medicare	$47.19
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Devoted Health Medicare	$51.91
Rate for Payer: Hawaii Medical Service Association Medicare	$47.19
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	$51.91
Rate for Payer: Kaiser Permanente Medicaid	$51.91
Rate for Payer: Kaiser Permanente Medicare	$51.91
Rate for Payer: Ohana Health Plan Medicaid	$88.11
Rate for Payer: Ohana Health Plan Medicare	$47.19
Rate for Payer: UnitedHealthcare Medicaid	$88.11
Rate for Payer: UnitedHealthcare Medicare	$47.19

CT Spine Cervical w/ + w/o Contrast

Facility

$1,869.00

Service Code	HCPCS 72127
Hospital Charge Code	1168236
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 Spine Cervical w/ + w/o Contrast

Facility

$1,869.00

Service Code	HCPCS 72127
Hospital Charge Code	1168236
Hospital Revenue Code	352
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	$291.10
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	$316.52
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	$291.10
Rate for Payer: UnitedHealthcare Medicare	$934.50
Rate for Payer: University Health Alliance Commercial	$789.62

CT Spine Cervical w/ + w/o Contrast - Report

Professional

Both

$205.00

Service Code	HCPCS 72127 26
Hospital Charge Code	629607
Hospital Revenue Code	972
Min. Negotiated Rate	$59.10
Max. Negotiated Rate	$458.37
Rate for Payer: AlohaCare Medicaid	$134.69
Rate for Payer: AlohaCare Medicare	$59.10
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$65.01
Rate for Payer: Hawaii Medical Service Association Medicare	$59.10
Rate for Payer: Hawaii Western Management Group Commercial	$458.37
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$65.01
Rate for Payer: Kaiser Permanente Medicaid	$65.01
Rate for Payer: Kaiser Permanente Medicare	$65.01
Rate for Payer: Ohana Health Plan Medicaid	$134.69
Rate for Payer: Ohana Health Plan Medicare	$59.10
Rate for Payer: UnitedHealthcare Medicaid	$134.69
Rate for Payer: UnitedHealthcare Medicare	$59.10

CT Spine Lumbar w/ Contrast

Facility

$2,034.00

Service Code	HCPCS 72132
Hospital Charge Code	1168244
Hospital Revenue Code	352
Min. Negotiated Rate	$1,728.90
Max. Negotiated Rate	$1,972.98
Rate for Payer: Cash Price	$1,322.10
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: Kaiser Permanente Commercial	$1,830.60
Rate for Payer: MDX Hawaii PPO	$1,972.98

CT Spine Lumbar w/ Contrast

Facility

$2,034.00

Service Code	HCPCS 72132
Hospital Charge Code	1168244
Hospital Revenue Code	352
Min. Negotiated Rate	$232.90
Max. Negotiated Rate	$1,972.98
Rate for Payer: AlohaCare Medicaid	$1,017.00
Rate for Payer: AlohaCare Medicare	$1,017.00
Rate for Payer: Cash Price	$1,322.10
Rate for Payer: Cash Price	$1,322.10
Rate for Payer: Devoted Health Medicare	$1,118.70
Rate for Payer: Hawaii Medical Service Association ABD	$232.90
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$1,017.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$253.12
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: Humana Medicare	$1,017.00
Rate for Payer: Kaiser Permanente Commercial	$1,830.60
Rate for Payer: Kaiser Permanente Medicaid	$1,037.34
Rate for Payer: Kaiser Permanente Medicare	$1,017.00
Rate for Payer: MDX Hawaii PPO	$1,972.98
Rate for Payer: Ohana Health Plan Medicaid	$1,017.00
Rate for Payer: Ohana Health Plan Medicare	$1,017.00
Rate for Payer: UnitedHealthcare Medicaid	$232.90
Rate for Payer: UnitedHealthcare Medicare	$1,017.00
Rate for Payer: University Health Alliance Commercial	$683.96

CT Spine Lumbar w/ Contrast - Report

Professional

Both

$352.00

Service Code	HCPCS 72132 26
Hospital Charge Code	630053
Hospital Revenue Code	972
Min. Negotiated Rate	$57.05
Max. Negotiated Rate	$377.36
Rate for Payer: AlohaCare Medicaid	$114.76
Rate for Payer: AlohaCare Medicare	$57.05
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cash Price	$228.80
Rate for Payer: Devoted Health Medicare	$62.76
Rate for Payer: Hawaii Medical Service Association Medicare	$57.05
Rate for Payer: Hawaii Western Management Group Commercial	$377.36
Rate for Payer: Health Management Network Commercial	$299.20
Rate for Payer: Kaiser Permanente Commercial	$62.76
Rate for Payer: Kaiser Permanente Medicaid	$62.76
Rate for Payer: Kaiser Permanente Medicare	$62.76
Rate for Payer: Ohana Health Plan Medicaid	$114.76
Rate for Payer: Ohana Health Plan Medicare	$57.05
Rate for Payer: UnitedHealthcare Medicaid	$114.76
Rate for Payer: UnitedHealthcare Medicare	$57.05

CT Spine Lumbar w/o Contrast

Facility

$1,103.00

Service Code	HCPCS 72131
Hospital Charge Code	1168246
Hospital Revenue Code	352
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$1,069.91
Rate for Payer: AlohaCare Medicaid	$551.50
Rate for Payer: AlohaCare Medicare	$551.50
Rate for Payer: Cash Price	$716.95
Rate for Payer: Cash Price	$716.95
Rate for Payer: Devoted Health Medicare	$606.65
Rate for Payer: Hawaii Medical Service Association ABD	$177.96
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$551.50
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	$937.55
Rate for Payer: Humana Medicare	$551.50
Rate for Payer: Kaiser Permanente Commercial	$992.70
Rate for Payer: Kaiser Permanente Medicaid	$562.53
Rate for Payer: Kaiser Permanente Medicare	$551.50
Rate for Payer: MDX Hawaii PPO	$1,069.91
Rate for Payer: Ohana Health Plan Medicaid	$551.50
Rate for Payer: Ohana Health Plan Medicare	$551.50
Rate for Payer: UnitedHealthcare Medicaid	$177.96
Rate for Payer: UnitedHealthcare Medicare	$551.50
Rate for Payer: University Health Alliance Commercial	$502.27

CT Spine Lumbar w/o Contrast

Facility

$1,103.00

Service Code	HCPCS 72131
Hospital Charge Code	1168246
Hospital Revenue Code	352
Min. Negotiated Rate	$937.55
Max. Negotiated Rate	$1,069.91
Rate for Payer: Cash Price	$716.95
Rate for Payer: Health Management Network Commercial	$937.55
Rate for Payer: Kaiser Permanente Commercial	$992.70
Rate for Payer: MDX Hawaii PPO	$1,069.91

CT Spine Lumbar w/o Contrast - Report

Professional

Both

$186.00

Service Code	HCPCS 72131 26
Hospital Charge Code	630057
Hospital Revenue Code	972
Min. Negotiated Rate	$47.19
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$87.42
Rate for Payer: AlohaCare Medicare	$47.19
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Devoted Health Medicare	$51.91
Rate for Payer: Hawaii Medical Service Association Medicare	$47.19
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	$51.91
Rate for Payer: Kaiser Permanente Medicaid	$51.91
Rate for Payer: Kaiser Permanente Medicare	$51.91
Rate for Payer: Ohana Health Plan Medicaid	$87.42
Rate for Payer: Ohana Health Plan Medicare	$47.19
Rate for Payer: UnitedHealthcare Medicaid	$87.42
Rate for Payer: UnitedHealthcare Medicare	$47.19

CT Spine Lumbar w/ + w/o Contrast

Facility

$1,542.00

Service Code	HCPCS 72133
Hospital Charge Code	1168242
Hospital Revenue Code	352
Min. Negotiated Rate	$1,310.70
Max. Negotiated Rate	$1,495.74
Rate for Payer: Cash Price	$1,002.30
Rate for Payer: Health Management Network Commercial	$1,310.70
Rate for Payer: Kaiser Permanente Commercial	$1,387.80
Rate for Payer: MDX Hawaii PPO	$1,495.74

CT Spine Lumbar w/ + w/o Contrast

Facility

$1,542.00

Service Code	HCPCS 72133
Hospital Charge Code	1168242
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$1,495.74
Rate for Payer: AlohaCare Medicaid	$771.00
Rate for Payer: AlohaCare Medicare	$771.00
Rate for Payer: Cash Price	$1,002.30
Rate for Payer: Cash Price	$1,002.30
Rate for Payer: Devoted Health Medicare	$848.10
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	$771.00
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	$1,310.70
Rate for Payer: Humana Medicare	$771.00
Rate for Payer: Kaiser Permanente Commercial	$1,387.80
Rate for Payer: Kaiser Permanente Medicaid	$786.42
Rate for Payer: Kaiser Permanente Medicare	$771.00
Rate for Payer: MDX Hawaii PPO	$1,495.74
Rate for Payer: Ohana Health Plan Medicaid	$771.00
Rate for Payer: Ohana Health Plan Medicare	$771.00
Rate for Payer: UnitedHealthcare Medicaid	$291.10
Rate for Payer: UnitedHealthcare Medicare	$771.00
Rate for Payer: University Health Alliance Commercial	$789.62

CT Spine Lumbar w/ + w/o Contrast - Report

Professional

Both

$277.00

Service Code	HCPCS 72133 26
Hospital Charge Code	630051
Hospital Revenue Code	972
Min. Negotiated Rate	$59.48
Max. Negotiated Rate	$458.37
Rate for Payer: AlohaCare Medicaid	$134.92
Rate for Payer: AlohaCare Medicare	$59.48
Rate for Payer: Cash Price	$180.05
Rate for Payer: Cash Price	$180.05
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	$458.37
Rate for Payer: Health Management Network Commercial	$235.45
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	$134.92
Rate for Payer: Ohana Health Plan Medicare	$59.48
Rate for Payer: UnitedHealthcare Medicaid	$134.92
Rate for Payer: UnitedHealthcare Medicare	$59.48

CT Spine Thoracic w/ Contrast

Facility

$1,728.00

Service Code	HCPCS 72129
Hospital Charge Code	1168250
Hospital Revenue Code	352
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 Spine Thoracic w/ Contrast

Facility

$1,728.00

Service Code	HCPCS 72129
Hospital Charge Code	1168250
Hospital Revenue Code	352
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	$232.90
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	$253.12
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	$232.90
Rate for Payer: UnitedHealthcare Medicare	$864.00
Rate for Payer: University Health Alliance Commercial	$684.78

CT Spine Thoracic w/ Contrast - Report

Professional

Both

$185.00

Service Code	HCPCS 72129 26
Hospital Charge Code	630169
Hospital Revenue Code	972
Min. Negotiated Rate	$57.05
Max. Negotiated Rate	$377.25
Rate for Payer: AlohaCare Medicaid	$115.33
Rate for Payer: AlohaCare Medicare	$57.05
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$62.76
Rate for Payer: Hawaii Medical Service Association Medicare	$57.05
Rate for Payer: Hawaii Western Management Group Commercial	$377.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$62.76
Rate for Payer: Kaiser Permanente Medicaid	$62.76
Rate for Payer: Kaiser Permanente Medicare	$62.76
Rate for Payer: Ohana Health Plan Medicaid	$115.33
Rate for Payer: Ohana Health Plan Medicare	$57.05
Rate for Payer: UnitedHealthcare Medicaid	$115.33
Rate for Payer: UnitedHealthcare Medicare	$57.05

CT Spine Thoracic w/o Contrast

Facility

$1,470.00

Service Code	HCPCS 72128
Hospital Charge Code	1168252
Hospital Revenue Code	352
Min. Negotiated Rate	$1,249.50
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$955.50
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: MDX Hawaii PPO	$1,425.90

CT Spine Thoracic w/o Contrast

Facility

$1,470.00

Service Code	HCPCS 72128
Hospital Charge Code	1168252
Hospital Revenue Code	352
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$1,425.90
Rate for Payer: AlohaCare Medicaid	$735.00
Rate for Payer: AlohaCare Medicare	$735.00
Rate for Payer: Cash Price	$955.50
Rate for Payer: Cash Price	$955.50
Rate for Payer: Devoted Health Medicare	$808.50
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	$735.00
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	$1,249.50
Rate for Payer: Humana Medicare	$735.00
Rate for Payer: Kaiser Permanente Commercial	$1,323.00
Rate for Payer: Kaiser Permanente Medicaid	$749.70
Rate for Payer: Kaiser Permanente Medicare	$735.00
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: Ohana Health Plan Medicaid	$735.00
Rate for Payer: Ohana Health Plan Medicare	$735.00
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$735.00
Rate for Payer: University Health Alliance Commercial	$502.27

CT Spine Thoracic w/o Contrast - Report

Professional

Both

$186.00

Service Code	HCPCS 72128 26
Hospital Charge Code	630173
Hospital Revenue Code	972
Min. Negotiated Rate	$47.19
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$87.88
Rate for Payer: AlohaCare Medicare	$47.19
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Devoted Health Medicare	$51.91
Rate for Payer: Hawaii Medical Service Association Medicare	$47.19
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	$51.91
Rate for Payer: Kaiser Permanente Medicaid	$51.91
Rate for Payer: Kaiser Permanente Medicare	$51.91
Rate for Payer: Ohana Health Plan Medicaid	$87.88
Rate for Payer: Ohana Health Plan Medicare	$47.19
Rate for Payer: UnitedHealthcare Medicaid	$87.88
Rate for Payer: UnitedHealthcare Medicare	$47.19

CT Spine Thoracic w/ + w/o Contrast

Facility

$2,056.00

Service Code	HCPCS 72130
Hospital Charge Code	1168248
Hospital Revenue Code	352
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	$291.10
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	$316.52
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	$291.10
Rate for Payer: UnitedHealthcare Medicare	$1,028.00
Rate for Payer: University Health Alliance Commercial	$789.62

Know your out-of-pocket cost for care.

All Charges