Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

MG Mammo Implant Digital Diag Right

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	2425814
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 Right

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	2425814
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 Right - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	2425816
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 Screening Bilat

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	2425817
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	$285.53

MG Mammo Implant Digital Screening Bilat

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	2425817
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 Implant Digital Screening Bilat - Report

Professional

Both

$114.00

Service Code	HCPCS 77067
Hospital Charge Code	2425819
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: AlohaCare Medicare	$139.23
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$153.15
Rate for Payer: Hawaii Medical Service Association Medicare	$139.23
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$153.15
Rate for Payer: Kaiser Permanente Medicaid	$153.15
Rate for Payer: Kaiser Permanente Medicare	$153.15
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: Ohana Health Plan Medicare	$139.23
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$139.23

MG Mammo Implant Digital Screening Left

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	2425820
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	$285.53

MG Mammo Implant Digital Screening Left

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	2425820
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 Implant Digital Screening Left - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	2425822
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	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Implant Digital Screening Right

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	2425823
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 Implant Digital Screening Right

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	2425823
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	$285.53

MG Mammo Implant Digital Screening Right - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	2425825
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	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Implant Screening Bil w/ Tomo.

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8033231
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	$285.53

MG Mammo Implant Screening Bil w/ Tomo.

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8033231
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 Implant Screening Bil w/ Tomo. - Report

Professional

Both

$114.00

Service Code	HCPCS 77067
Hospital Charge Code	8033233
Hospital Revenue Code	972
Min. Negotiated Rate	$85.27
Max. Negotiated Rate	$156.36
Rate for Payer: AlohaCare Medicaid	$85.27
Rate for Payer: AlohaCare Medicare	$139.23
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$153.15
Rate for Payer: Hawaii Medical Service Association Medicare	$139.23
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$153.15
Rate for Payer: Kaiser Permanente Medicaid	$153.15
Rate for Payer: Kaiser Permanente Medicare	$153.15
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: Ohana Health Plan Medicare	$139.23
Rate for Payer: UnitedHealthcare Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicare	$139.23

MG Mammo Implant Screening Lt w/ Tomo.

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033234
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 Implant Screening Lt w/ Tomo.

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033234
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	$285.53

MG Mammo Implant Screening Lt w/ Tomo. - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033236
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	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Implant Screening Rt w/ Tomo.

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033237
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	$285.53

MG Mammo Implant Screening Rt w/ Tomo.

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033237
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 Implant Screening Rt w/ Tomo. - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033239
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	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Hawaii Western Management Group Commercial	$156.36
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Ohana Health Plan Medicaid	$85.27
Rate for Payer: UnitedHealthcare Medicaid	$85.27

MG Mammo Post Clip Placement Left

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	5182314
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 Post Clip Placement Left

Facility

$576.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	5182314
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 Post Clip Placement Left - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	5182316
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 Post Clip Placement Right

Facility

$576.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	5182317
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