Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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 Right - Report

Professional

Both

$108.00

Service Code	HCPCS 77065 RT
Hospital Charge Code	5182319
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 Screening Bilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8033240
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 Screening Bilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8352756
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 Screening Bilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8033240
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 Screening Bilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067
Hospital Charge Code	8352756
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 Screening Bilateral w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 26
Hospital Charge Code	8033242
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	$74.10
Rate for Payer: Cash Price	$74.10
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	$96.90
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 Screening Bilateral w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067
Hospital Charge Code	8352758
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 Screening Left w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8352759
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 Screening Left w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8352759
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 Screening Left w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033245
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 Screening Left w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8352761
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 Screening Right w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8352762
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 Screening Right w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8352762
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 Screening Right w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8352764
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 Screening Right w/ Tomo - Report

Professional

Both

$114.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033248
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 Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033243
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 Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,LT
Hospital Charge Code	8033243
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 Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033246
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 Screening Unilateral w/ Tomo

Facility

$464.00

Service Code	HCPCS 77067 52,RT
Hospital Charge Code	8033246
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

M Hominis Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023502
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$354.05
Rate for Payer: AlohaCare Medicaid	$182.50
Rate for Payer: AlohaCare Medicare	$182.50
Rate for Payer: Cash Price	$237.25
Rate for Payer: Cash Price	$237.25
Rate for Payer: Devoted Health Medicare	$200.75
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$182.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Humana Medicare	$182.50
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: Kaiser Permanente Medicare	$182.50
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: Ohana Health Plan Medicaid	$182.50
Rate for Payer: Ohana Health Plan Medicare	$182.50
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$182.50
Rate for Payer: University Health Alliance Commercial	$90.72

M Hominis Amp Probe

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	10023502
Hospital Revenue Code	306
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$237.25
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: MDX Hawaii PPO	$354.05

micafungin 100 mg vial [HHSC]

Facility

$300.88

Service Code	HCPCS J2248
Hospital Charge Code	2501107
Hospital Revenue Code	250
Min. Negotiated Rate	$255.75
Max. Negotiated Rate	$291.85
Rate for Payer: Cash Price	$195.57
Rate for Payer: Health Management Network Commercial	$255.75
Rate for Payer: Kaiser Permanente Commercial	$270.79
Rate for Payer: MDX Hawaii PPO	$291.85

micafungin 100 mg vial [HHSC]

Facility

$300.88

Service Code	HCPCS J2248
Hospital Charge Code	2501107
Hospital Revenue Code	636
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$291.85
Rate for Payer: AlohaCare Medicaid	$150.44
Rate for Payer: AlohaCare Medicare	$150.44
Rate for Payer: Cash Price	$195.57
Rate for Payer: Cash Price	$195.57
Rate for Payer: Devoted Health Medicare	$165.48
Rate for Payer: Hawaii Medical Service Association ABD	$0.31
Rate for Payer: Hawaii Medical Service Association Medicare	$150.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$285.84
Rate for Payer: Health Management Network Commercial	$255.75
Rate for Payer: Humana Medicare	$150.44
Rate for Payer: Kaiser Permanente Commercial	$270.79
Rate for Payer: Kaiser Permanente Medicaid	$153.45
Rate for Payer: Kaiser Permanente Medicare	$150.44
Rate for Payer: MDX Hawaii PPO	$291.85
Rate for Payer: Ohana Health Plan Medicaid	$150.44
Rate for Payer: Ohana Health Plan Medicare	$150.44
Rate for Payer: UnitedHealthcare Medicaid	$180.53
Rate for Payer: UnitedHealthcare Medicare	$150.44
Rate for Payer: University Health Alliance Commercial	$219.31

miconazole 2% cream vaginal [HHSC]

Facility

$66.01

Service Code	NDC 51672203506
Hospital Charge Code	2500548
Hospital Revenue Code	250
Min. Negotiated Rate	$33.01
Max. Negotiated Rate	$64.03
Rate for Payer: AlohaCare Medicaid	$33.01
Rate for Payer: AlohaCare Medicare	$33.01
Rate for Payer: Cash Price	$42.91
Rate for Payer: Devoted Health Medicare	$36.31
Rate for Payer: Hawaii Medical Service Association Medicare	$33.01
Rate for Payer: Hawaii Western Management Group Commercial	$62.71
Rate for Payer: Health Management Network Commercial	$56.11
Rate for Payer: Humana Medicare	$33.01
Rate for Payer: Kaiser Permanente Commercial	$59.41
Rate for Payer: Kaiser Permanente Medicaid	$33.67
Rate for Payer: Kaiser Permanente Medicare	$33.01
Rate for Payer: MDX Hawaii PPO	$64.03
Rate for Payer: Ohana Health Plan Medicaid	$33.01
Rate for Payer: Ohana Health Plan Medicare	$33.01
Rate for Payer: UnitedHealthcare Medicaid	$39.61
Rate for Payer: UnitedHealthcare Medicare	$33.01
Rate for Payer: University Health Alliance Commercial	$48.11

Know your out-of-pocket cost for care.

All Charges