Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

MG Mammo Digital Screening Left. - Report

Professional

Both

$128.00

Service Code	HCPCS 77067 26,52
Hospital Charge Code	8033202
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Digital Screening Right.

Facility

$464.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	8033203
Hospital Revenue Code	403
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$450.08
Rate for Payer: Cash Price	$301.60
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: MDX Hawaii PPO	$450.08

MG Mammo Digital Screening Right.

Facility

$464.00

Service Code	HCPCS 77067 TC
Hospital Charge Code	8033203
Hospital Revenue Code	403
Min. Negotiated Rate	$80.77
Max. Negotiated Rate	$450.08
Rate for Payer: AlohaCare Medicaid	$232.00
Rate for Payer: AlohaCare Medicare	$232.00
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cash Price	$301.60
Rate for Payer: Devoted Health Medicare	$255.20
Rate for Payer: Hawaii Medical Service Association ABD	$80.77
Rate for Payer: Hawaii Medical Service Association Medicare	$232.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.74
Rate for Payer: Hawaii Western Management Group Commercial	$440.80
Rate for Payer: Health Management Network Commercial	$394.40
Rate for Payer: Humana Medicare	$232.00
Rate for Payer: Kaiser Permanente Commercial	$417.60
Rate for Payer: Kaiser Permanente Medicaid	$236.64
Rate for Payer: Kaiser Permanente Medicare	$232.00
Rate for Payer: MDX Hawaii PPO	$450.08
Rate for Payer: Ohana Health Plan Medicaid	$232.00
Rate for Payer: Ohana Health Plan Medicare	$232.00
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$232.00
Rate for Payer: University Health Alliance Commercial	$214.17

MG Mammo Digital Screening Right. - Report

Professional

Both

$128.00

Service Code	HCPCS 77067 26
Hospital Charge Code	8033205
Hospital Revenue Code	972
Min. Negotiated Rate	$35.74
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: AlohaCare Medicare	$35.74
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$39.31
Rate for Payer: Hawaii Medical Service Association Medicare	$35.74
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$39.31
Rate for Payer: Kaiser Permanente Medicaid	$39.31
Rate for Payer: Kaiser Permanente Medicare	$39.31
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: Ohana Health Plan Medicare	$35.74
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$35.74

MG Mammo Implant Diag Bilateral w/ Tomo.

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8033206
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 Implant Diag Bilateral w/ Tomo.

Facility

$802.00

Service Code	HCPCS 77066
Hospital Charge Code	8033206
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 Implant Diag Bilateral w/ Tomo. - Report

Professional

Both

$138.00

Service Code	HCPCS 77066
Hospital Charge Code	8033208
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 Implant Diag Left w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8818497
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 Implant Diag Left w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8818497
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 Implant Diag Left w/ Tomo.

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8033209
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 Implant Diag Left w/ Tomo.

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8033209
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 Implant Diag Left w/ Tomo - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8818499
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Implant Diag Left w/ Tomo. - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	8033211
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Implant Diag Right w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8818500
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 Implant Diag Right w/ Tomo

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8818500
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 Implant Diag Right w/ Tomo.

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8033212
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 Implant Diag Right w/ Tomo.

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8033212
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 Implant Diag Right w/ Tomo - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8818502
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Implant Diag Right w/ Tomo. - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	8033214
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

MG Mammo Implant Digital Diag Bilateral

Facility

$1,023.00

Service Code	HCPCS 77066
Hospital Charge Code	2425808
Hospital Revenue Code	401
Min. Negotiated Rate	$869.55
Max. Negotiated Rate	$992.31
Rate for Payer: Cash Price	$664.95
Rate for Payer: Health Management Network Commercial	$869.55
Rate for Payer: Kaiser Permanente Commercial	$920.70
Rate for Payer: MDX Hawaii PPO	$992.31

MG Mammo Implant Digital Diag Bilateral

Facility

$1,023.00

Service Code	HCPCS 77066
Hospital Charge Code	2425808
Hospital Revenue Code	401
Min. Negotiated Rate	$77.83
Max. Negotiated Rate	$992.31
Rate for Payer: AlohaCare Medicaid	$511.50
Rate for Payer: AlohaCare Medicare	$511.50
Rate for Payer: Cash Price	$664.95
Rate for Payer: Cash Price	$664.95
Rate for Payer: Devoted Health Medicare	$562.65
Rate for Payer: Hawaii Medical Service Association ABD	$77.83
Rate for Payer: Hawaii Medical Service Association Medicare	$511.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.42
Rate for Payer: Hawaii Western Management Group Commercial	$971.85
Rate for Payer: Health Management Network Commercial	$869.55
Rate for Payer: Humana Medicare	$511.50
Rate for Payer: Kaiser Permanente Commercial	$920.70
Rate for Payer: Kaiser Permanente Medicaid	$521.73
Rate for Payer: Kaiser Permanente Medicare	$511.50
Rate for Payer: MDX Hawaii PPO	$992.31
Rate for Payer: Ohana Health Plan Medicaid	$511.50
Rate for Payer: Ohana Health Plan Medicare	$511.50
Rate for Payer: UnitedHealthcare Medicaid	$105.44
Rate for Payer: UnitedHealthcare Medicare	$511.50
Rate for Payer: University Health Alliance Commercial	$352.89

MG Mammo Implant Digital Diag Bilateral - Report

Professional

Both

$138.00

Service Code	HCPCS 77066
Hospital Charge Code	2425810
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 Implant Digital Diag Left

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	2425811
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 Implant Digital Diag Left

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	2425811
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 Implant Digital Diag Left - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	2425813
Hospital Revenue Code	972
Min. Negotiated Rate	$83.29
Max. Negotiated Rate	$141.22
Rate for Payer: AlohaCare Medicaid	$83.29
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Ohana Health Plan Medicaid	$83.29
Rate for Payer: UnitedHealthcare Medicaid	$83.29

Know your out-of-pocket cost for care.

All Charges