Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

MG Ductogram or Galactogram Multiple Rt.

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8253565
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Multiple Rt.

Facility

$740.00

Service Code	HCPCS 77054
Hospital Charge Code	8253565
Hospital Revenue Code	320
Min. Negotiated Rate	$95.49
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$95.49
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.78
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$95.49
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$258.46

MG Ductogram or Galactogram Multiple Rt - Report

Professional

Both

$332.00

Service Code	HCPCS 77054 26,RT
Hospital Charge Code	8099878
Hospital Revenue Code	972
Min. Negotiated Rate	$46.04
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$46.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$46.04
Rate for Payer: UnitedHealthcare Medicaid	$46.04

MG Ductogram or Galactogram Multiple Rt. - Report

Professional

Both

$332.00

Service Code	HCPCS 77054 26,RT
Hospital Charge Code	8253567
Hospital Revenue Code	972
Min. Negotiated Rate	$46.04
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$46.04
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$46.04
Rate for Payer: UnitedHealthcare Medicaid	$46.04

MG Ductogram or Galactogram Single Left

Facility

$740.00

Service Code	HCPCS 77053 LT
Hospital Charge Code	969793
Hospital Revenue Code	320
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$64.63
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$88.66
Rate for Payer: Hawaii Western Management Group Commercial	$703.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$64.63
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$190.18

MG Ductogram or Galactogram Single Left

Facility

$740.00

Service Code	HCPCS 77053 LT
Hospital Charge Code	969793
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Single Left.

Facility

$740.00

Service Code	HCPCS 77053 LT
Hospital Charge Code	8033168
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Single Left.

Facility

$740.00

Service Code	HCPCS 77053 LT
Hospital Charge Code	8033168
Hospital Revenue Code	320
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$64.63
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$88.66
Rate for Payer: Hawaii Western Management Group Commercial	$703.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$64.63
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$190.18

MG Ductogram or Galactogram Single Left - Report

Professional

Both

$332.00

Service Code	HCPCS 77053 26,LT
Hospital Charge Code	630674
Hospital Revenue Code	972
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$35.75
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$35.75
Rate for Payer: UnitedHealthcare Medicaid	$35.75

MG Ductogram or Galactogram Single Right

Facility

$740.00

Service Code	HCPCS 77053 RT
Hospital Charge Code	8033171
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Single Right

Facility

$740.00

Service Code	HCPCS 77053 RT
Hospital Charge Code	969795
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

MG Ductogram or Galactogram Single Right

Facility

$740.00

Service Code	HCPCS 77053 RT
Hospital Charge Code	8033171
Hospital Revenue Code	320
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$64.63
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$88.66
Rate for Payer: Hawaii Western Management Group Commercial	$703.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$64.63
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$190.18

MG Ductogram or Galactogram Single Right

Facility

$740.00

Service Code	HCPCS 77053 RT
Hospital Charge Code	969795
Hospital Revenue Code	320
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$64.63
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$88.66
Rate for Payer: Hawaii Western Management Group Commercial	$703.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$64.63
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$190.18

MG Ductogram or Galactogram Single Right - Report

Professional

Both

$332.00

Service Code	HCPCS 77053 26,RT
Hospital Charge Code	630678
Hospital Revenue Code	972
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$35.75
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$35.75
Rate for Payer: UnitedHealthcare Medicaid	$35.75

MG Ductogram or Galactogram Single Rt. - Report

Professional

Both

$332.00

Service Code	HCPCS 77053 26,RT
Hospital Charge Code	8033172
Hospital Revenue Code	972
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$35.75
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Ohana Health Plan Medicaid	$35.75
Rate for Payer: UnitedHealthcare Medicaid	$35.75

MG Mammo Diagnostic Bilateral w/ Tomo

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8420275
Hospital Revenue Code	403
Min. Negotiated Rate	$681.70
Max. Negotiated Rate	$777.94
Rate for Payer: Cash Price	$521.30
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: MDX Hawaii PPO	$777.94

MG Mammo Diagnostic Bilateral w/ Tomo

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8033179
Hospital Revenue Code	401
Min. Negotiated Rate	$77.83
Max. Negotiated Rate	$777.94
Rate for Payer: AlohaCare Medicaid	$401.00
Rate for Payer: AlohaCare Medicare	$401.00
Rate for Payer: Cash Price	$521.30
Rate for Payer: Cash Price	$521.30
Rate for Payer: Devoted Health Medicare	$441.10
Rate for Payer: Hawaii Medical Service Association ABD	$77.83
Rate for Payer: Hawaii Medical Service Association Medicare	$401.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.42
Rate for Payer: Hawaii Western Management Group Commercial	$761.90
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Humana Medicare	$401.00
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: Kaiser Permanente Medicaid	$409.02
Rate for Payer: Kaiser Permanente Medicare	$401.00
Rate for Payer: MDX Hawaii PPO	$777.94
Rate for Payer: Ohana Health Plan Medicaid	$401.00
Rate for Payer: Ohana Health Plan Medicare	$401.00
Rate for Payer: UnitedHealthcare Medicaid	$105.44
Rate for Payer: UnitedHealthcare Medicare	$401.00
Rate for Payer: University Health Alliance Commercial	$352.89

MG Mammo Diagnostic Bilateral w/ Tomo

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8420275
Hospital Revenue Code	403
Min. Negotiated Rate	$77.83
Max. Negotiated Rate	$777.94
Rate for Payer: AlohaCare Medicaid	$401.00
Rate for Payer: AlohaCare Medicare	$401.00
Rate for Payer: Cash Price	$521.30
Rate for Payer: Cash Price	$521.30
Rate for Payer: Devoted Health Medicare	$441.10
Rate for Payer: Hawaii Medical Service Association ABD	$77.83
Rate for Payer: Hawaii Medical Service Association Medicare	$401.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.42
Rate for Payer: Hawaii Western Management Group Commercial	$761.90
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Humana Medicare	$401.00
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: Kaiser Permanente Medicaid	$409.02
Rate for Payer: Kaiser Permanente Medicare	$401.00
Rate for Payer: MDX Hawaii PPO	$777.94
Rate for Payer: Ohana Health Plan Medicaid	$401.00
Rate for Payer: Ohana Health Plan Medicare	$401.00
Rate for Payer: UnitedHealthcare Medicaid	$105.44
Rate for Payer: UnitedHealthcare Medicare	$401.00
Rate for Payer: University Health Alliance Commercial	$352.89

MG Mammo Diagnostic Bilateral w/ Tomo

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8033179
Hospital Revenue Code	401
Min. Negotiated Rate	$681.70
Max. Negotiated Rate	$777.94
Rate for Payer: Cash Price	$521.30
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: MDX Hawaii PPO	$777.94

MG Mammo Diagnostic Bilateral w/ Tomo - Report

Professional

Both

$138.00

Service Code	HCPCS 77066
Hospital Charge Code	8420277
Hospital Revenue Code	972
Min. Negotiated Rate	$105.44
Max. Negotiated Rate	$189.77
Rate for Payer: AlohaCare Medicaid	$105.44
Rate for Payer: AlohaCare Medicare	$172.52
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$189.77
Rate for Payer: Hawaii Medical Service Association Medicare	$172.52
Rate for Payer: Hawaii Western Management Group Commercial	$161.84
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$189.77
Rate for Payer: Kaiser Permanente Medicaid	$189.77
Rate for Payer: Kaiser Permanente Medicare	$189.77
Rate for Payer: Ohana Health Plan Medicaid	$105.44
Rate for Payer: Ohana Health Plan Medicare	$172.52
Rate for Payer: UnitedHealthcare Medicaid	$105.44
Rate for Payer: UnitedHealthcare Medicare	$172.52

MG Mammo Diagnostic Bilateral w/ Tomo. - Report

Professional

Both

$138.00

Service Code	HCPCS 77066
Hospital Charge Code	8033181
Hospital Revenue Code	972
Min. Negotiated Rate	$105.44
Max. Negotiated Rate	$189.77
Rate for Payer: AlohaCare Medicaid	$105.44
Rate for Payer: AlohaCare Medicare	$172.52
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$189.77
Rate for Payer: Hawaii Medical Service Association Medicare	$172.52
Rate for Payer: Hawaii Western Management Group Commercial	$161.84
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$189.77
Rate for Payer: Kaiser Permanente Medicaid	$189.77
Rate for Payer: Kaiser Permanente Medicare	$189.77
Rate for Payer: Ohana Health Plan Medicaid	$105.44
Rate for Payer: Ohana Health Plan Medicare	$172.52
Rate for Payer: UnitedHealthcare Medicaid	$105.44
Rate for Payer: UnitedHealthcare Medicare	$172.52

MG Mammo Diagnostic Left w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8420278
Hospital Revenue Code	401
Min. Negotiated Rate	$64.13
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$288.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Devoted Health Medicare	$316.80
Rate for Payer: Hawaii Medical Service Association ABD	$64.13
Rate for Payer: Hawaii Medical Service Association Medicare	$288.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.82
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$288.00
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$288.00
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$288.00
Rate for Payer: Ohana Health Plan Medicare	$288.00
Rate for Payer: UnitedHealthcare Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicare	$288.00
Rate for Payer: University Health Alliance Commercial	$277.78

MG Mammo Diagnostic Left w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8420278
Hospital Revenue Code	401
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

MG Mammo Diagnostic Left w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8033182
Hospital Revenue Code	401
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$558.72
Rate for Payer: Cash Price	$374.40
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: MDX Hawaii PPO	$558.72

MG Mammo Diagnostic Left w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8033182
Hospital Revenue Code	401
Min. Negotiated Rate	$64.13
Max. Negotiated Rate	$558.72
Rate for Payer: AlohaCare Medicaid	$288.00
Rate for Payer: AlohaCare Medicare	$288.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Devoted Health Medicare	$316.80
Rate for Payer: Hawaii Medical Service Association ABD	$64.13
Rate for Payer: Hawaii Medical Service Association Medicare	$288.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.82
Rate for Payer: Hawaii Western Management Group Commercial	$547.20
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Humana Medicare	$288.00
Rate for Payer: Kaiser Permanente Commercial	$518.40
Rate for Payer: Kaiser Permanente Medicaid	$293.76
Rate for Payer: Kaiser Permanente Medicare	$288.00
Rate for Payer: MDX Hawaii PPO	$558.72
Rate for Payer: Ohana Health Plan Medicaid	$288.00
Rate for Payer: Ohana Health Plan Medicare	$288.00
Rate for Payer: UnitedHealthcare Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicare	$288.00
Rate for Payer: University Health Alliance Commercial	$277.78

Know your out-of-pocket cost for care.

All Charges