Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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

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

Professional

Both

$278.00

Service Code	HCPCS 72130 26
Hospital Charge Code	630166
Hospital Revenue Code	972
Min. Negotiated Rate	$59.48
Max. Negotiated Rate	$458.37
Rate for Payer: AlohaCare Medicaid	$135.61
Rate for Payer: AlohaCare Medicare	$59.48
Rate for Payer: Cash Price	$180.70
Rate for Payer: Cash Price	$180.70
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	$236.30
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	$135.61
Rate for Payer: Ohana Health Plan Medicare	$59.48
Rate for Payer: UnitedHealthcare Medicaid	$135.61
Rate for Payer: UnitedHealthcare Medicare	$59.48

CT Thoracentesis w/ CT Guidance

Facility

$1,802.00

Service Code	HCPCS 32555
Hospital Charge Code	2424869
Hospital Revenue Code	350
Min. Negotiated Rate	$1,531.70
Max. Negotiated Rate	$1,747.94
Rate for Payer: Cash Price	$1,171.30
Rate for Payer: Health Management Network Commercial	$1,531.70
Rate for Payer: Kaiser Permanente Commercial	$1,621.80
Rate for Payer: MDX Hawaii PPO	$1,747.94

CT Thoracentesis w/ CT Guidance

Facility

$1,802.00

Service Code	HCPCS 32555
Hospital Charge Code	2424869
Hospital Revenue Code	350
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$901.00
Rate for Payer: AlohaCare Medicare	$901.00
Rate for Payer: Cash Price	$1,171.30
Rate for Payer: Cash Price	$1,171.30
Rate for Payer: Devoted Health Medicare	$991.10
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	$901.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,711.90
Rate for Payer: Health Management Network Commercial	$1,531.70
Rate for Payer: Humana Medicare	$901.00
Rate for Payer: Kaiser Permanente Commercial	$1,621.80
Rate for Payer: Kaiser Permanente Medicaid	$919.02
Rate for Payer: Kaiser Permanente Medicare	$901.00
Rate for Payer: MDX Hawaii PPO	$1,747.94
Rate for Payer: Ohana Health Plan Medicaid	$901.00
Rate for Payer: Ohana Health Plan Medicare	$901.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$901.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

CT Thoracentesis w/ CT Guidance - Report

Professional

Both

$873.00

Service Code	HCPCS 32555
Hospital Charge Code	2424871
Hospital Revenue Code	972
Min. Negotiated Rate	$92.50
Max. Negotiated Rate	$742.05
Rate for Payer: AlohaCare Medicaid	$106.83
Rate for Payer: AlohaCare Medicare	$92.50
Rate for Payer: Cash Price	$567.45
Rate for Payer: Cash Price	$567.45
Rate for Payer: Devoted Health Medicare	$101.75
Rate for Payer: Hawaii Medical Service Association ABD	$106.83
Rate for Payer: Hawaii Medical Service Association Commercial	$182.66
Rate for Payer: Hawaii Medical Service Association Medicare	$92.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.83
Rate for Payer: Health Management Network Commercial	$742.05
Rate for Payer: Kaiser Permanente Commercial	$101.75
Rate for Payer: Kaiser Permanente Medicaid	$101.75
Rate for Payer: Kaiser Permanente Medicare	$101.75
Rate for Payer: Ohana Health Plan Medicaid	$106.83
Rate for Payer: Ohana Health Plan Medicare	$92.50
Rate for Payer: UnitedHealthcare Medicaid	$106.83
Rate for Payer: UnitedHealthcare Medicare	$92.50
Rate for Payer: University Health Alliance Commercial	$132.55

CT Upper Extremity w/ Contrast Left

Facility

$2,261.00

Service Code	HCPCS 73201 LT
Hospital Charge Code	1168311
Hospital Revenue Code	352
Min. Negotiated Rate	$194.84
Max. Negotiated Rate	$2,193.17
Rate for Payer: AlohaCare Medicaid	$1,130.50
Rate for Payer: AlohaCare Medicare	$1,130.50
Rate for Payer: Cash Price	$1,469.65
Rate for Payer: Cash Price	$1,469.65
Rate for Payer: Devoted Health Medicare	$1,243.55
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,130.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$2,147.95
Rate for Payer: Health Management Network Commercial	$1,921.85
Rate for Payer: Humana Medicare	$1,130.50
Rate for Payer: Kaiser Permanente Commercial	$2,034.90
Rate for Payer: Kaiser Permanente Medicaid	$1,153.11
Rate for Payer: Kaiser Permanente Medicare	$1,130.50
Rate for Payer: MDX Hawaii PPO	$2,193.17
Rate for Payer: Ohana Health Plan Medicaid	$1,130.50
Rate for Payer: Ohana Health Plan Medicare	$1,130.50
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$1,130.50
Rate for Payer: University Health Alliance Commercial	$659.17

CT Upper Extremity w/ Contrast Left

Facility

$2,261.00

Service Code	HCPCS 73201 LT
Hospital Charge Code	1168311
Hospital Revenue Code	352
Min. Negotiated Rate	$1,921.85
Max. Negotiated Rate	$2,193.17
Rate for Payer: Cash Price	$1,469.65
Rate for Payer: Health Management Network Commercial	$1,921.85
Rate for Payer: Kaiser Permanente Commercial	$2,034.90
Rate for Payer: MDX Hawaii PPO	$2,193.17

CT Upper Extremity w/ Contrast Left - Report

Professional

Both

$320.00

Service Code	HCPCS 73201 26,LT
Hospital Charge Code	630223
Hospital Revenue Code	972
Min. Negotiated Rate	$137.43
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$137.43
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$272.00
Rate for Payer: Ohana Health Plan Medicaid	$137.43
Rate for Payer: UnitedHealthcare Medicaid	$137.43

CT Upper Extremity w/ Contrast Right

Facility

$2,065.00

Service Code	HCPCS 73201 RT
Hospital Charge Code	1168313
Hospital Revenue Code	352
Min. Negotiated Rate	$194.84
Max. Negotiated Rate	$2,003.05
Rate for Payer: AlohaCare Medicaid	$1,032.50
Rate for Payer: AlohaCare Medicare	$1,032.50
Rate for Payer: Cash Price	$1,342.25
Rate for Payer: Cash Price	$1,342.25
Rate for Payer: Devoted Health Medicare	$1,135.75
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Medicare	$1,032.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$1,961.75
Rate for Payer: Health Management Network Commercial	$1,755.25
Rate for Payer: Humana Medicare	$1,032.50
Rate for Payer: Kaiser Permanente Commercial	$1,858.50
Rate for Payer: Kaiser Permanente Medicaid	$1,053.15
Rate for Payer: Kaiser Permanente Medicare	$1,032.50
Rate for Payer: MDX Hawaii PPO	$2,003.05
Rate for Payer: Ohana Health Plan Medicaid	$1,032.50
Rate for Payer: Ohana Health Plan Medicare	$1,032.50
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$1,032.50
Rate for Payer: University Health Alliance Commercial	$659.17

CT Upper Extremity w/ Contrast Right

Facility

$2,065.00

Service Code	HCPCS 73201 RT
Hospital Charge Code	1168313
Hospital Revenue Code	352
Min. Negotiated Rate	$1,755.25
Max. Negotiated Rate	$2,003.05
Rate for Payer: Cash Price	$1,342.25
Rate for Payer: Health Management Network Commercial	$1,755.25
Rate for Payer: Kaiser Permanente Commercial	$1,858.50
Rate for Payer: MDX Hawaii PPO	$2,003.05

CT Upper Extremity w/ Contrast Right - Report

Professional

Both

$365.00

Service Code	HCPCS 73201 26,RT
Hospital Charge Code	630236
Hospital Revenue Code	972
Min. Negotiated Rate	$137.43
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$137.43
Rate for Payer: Cash Price	$237.25
Rate for Payer: Cash Price	$237.25
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Ohana Health Plan Medicaid	$137.43
Rate for Payer: UnitedHealthcare Medicaid	$137.43

CT Upper Extremity w/o Contrast Left

Facility

$1,651.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	1168323
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 Upper Extremity w/o Contrast Left

Facility

$1,651.00

Service Code	HCPCS 73200 LT
Hospital Charge Code	1168323
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 Upper Extremity w/o Contrast Left - Report

Professional

Both

$186.00

Service Code	HCPCS 73200 26,LT
Hospital Charge Code	630242
Hospital Revenue Code	972
Min. Negotiated Rate	$110.14
Max. Negotiated Rate	$277.05
Rate for Payer: AlohaCare Medicaid	$110.14
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	$110.14
Rate for Payer: UnitedHealthcare Medicaid	$110.14

CT Upper Extremity w/o Contrast Right

Facility

$1,651.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	1168325
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 Upper Extremity w/o Contrast Right

Facility

$1,651.00

Service Code	HCPCS 73200 RT
Hospital Charge Code	1168325
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 Upper Extremity w/o Contrast Right - Report

Professional

Both

$209.00

Service Code	HCPCS 73200 26,RT
Hospital Charge Code	630244
Hospital Revenue Code	972
Min. Negotiated Rate	$110.14
Max. Negotiated Rate	$277.05
Rate for Payer: AlohaCare Medicaid	$110.14
Rate for Payer: Cash Price	$135.85
Rate for Payer: Cash Price	$135.85
Rate for Payer: Hawaii Western Management Group Commercial	$277.05
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Ohana Health Plan Medicaid	$110.14
Rate for Payer: UnitedHealthcare Medicaid	$110.14

CT Upper Extremity w/+w/o Contrast Left

Facility

$2,224.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	1168317
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	$267.75
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	$785.42

CT Upper Extremity w/+w/o Contrast Left

Facility

$2,224.00

Service Code	HCPCS 73202 LT
Hospital Charge Code	1168317
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 Upper Extremity w/+w/o Contrast Left - Report

Professional

Both

$322.00

Service Code	HCPCS 73202 26,LT
Hospital Charge Code	630212
Hospital Revenue Code	972
Min. Negotiated Rate	$171.21
Max. Negotiated Rate	$392.99
Rate for Payer: AlohaCare Medicaid	$171.21
Rate for Payer: Cash Price	$209.30
Rate for Payer: Cash Price	$209.30
Rate for Payer: Hawaii Western Management Group Commercial	$392.99
Rate for Payer: Health Management Network Commercial	$273.70
Rate for Payer: Ohana Health Plan Medicaid	$171.21
Rate for Payer: UnitedHealthcare Medicaid	$171.21

CT Upper Extremity w/+w/o Contrast Right

Facility

$2,224.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	1168319
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 Upper Extremity w/+w/o Contrast Right

Facility

$2,224.00

Service Code	HCPCS 73202 RT
Hospital Charge Code	1168319
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	$267.75
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	$785.42

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

Professional

Both

$322.00

Service Code	HCPCS 73202 26,RT
Hospital Charge Code	630214
Hospital Revenue Code	972
Min. Negotiated Rate	$171.21
Max. Negotiated Rate	$392.99
Rate for Payer: AlohaCare Medicaid	$171.21
Rate for Payer: Cash Price	$209.30
Rate for Payer: Cash Price	$209.30
Rate for Payer: Hawaii Western Management Group Commercial	$392.99
Rate for Payer: Health Management Network Commercial	$273.70
Rate for Payer: Ohana Health Plan Medicaid	$171.21
Rate for Payer: UnitedHealthcare Medicaid	$171.21

Culture, Aerobic & Anaerobic w/Gram Stain

Facility

$240.00

Service Code	HCPCS 87205
Hospital Charge Code	12540253
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$232.80
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$120.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$132.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$120.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$120.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: Kaiser Permanente Medicare	$120.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$120.00
Rate for Payer: Ohana Health Plan Medicare	$120.00
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$120.00
Rate for Payer: University Health Alliance Commercial	$11.03

Culture, Aerobic & Anaerobic w/Gram Stain

Facility

$240.00

Service Code	HCPCS 87205
Hospital Charge Code	12540253
Hospital Revenue Code	306
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

Know your out-of-pocket cost for care.

All Charges