Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

MRI UE Joint w/ + w/o Contrast Left - Report

Professional

Both

$546.00

Service Code	HCPCS 73223 26,LT
Hospital Charge Code	8211757
Hospital Revenue Code	972
Min. Negotiated Rate	$266.19
Max. Negotiated Rate	$1,201.84
Rate for Payer: AlohaCare Medicaid	$266.19
Rate for Payer: Cash Price	$354.90
Rate for Payer: Cash Price	$354.90
Rate for Payer: Hawaii Western Management Group Commercial	$1,201.84
Rate for Payer: Health Management Network Commercial	$464.10
Rate for Payer: Ohana Health Plan Medicaid	$266.19
Rate for Payer: UnitedHealthcare Medicaid	$266.19

MRI UE Joint w/ + w/o Contrast Right

Facility

$2,934.00

Service Code	HCPCS 73223 RT
Hospital Charge Code	8211758
Hospital Revenue Code	610
Min. Negotiated Rate	$952.52
Max. Negotiated Rate	$2,845.98
Rate for Payer: AlohaCare Medicaid	$1,467.00
Rate for Payer: AlohaCare Medicare	$1,467.00
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Devoted Health Medicare	$1,613.70
Rate for Payer: Hawaii Medical Service Association ABD	$983.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,467.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$952.52
Rate for Payer: Hawaii Western Management Group Commercial	$2,787.30
Rate for Payer: Health Management Network Commercial	$2,493.90
Rate for Payer: Humana Medicare	$1,467.00
Rate for Payer: Kaiser Permanente Commercial	$2,640.60
Rate for Payer: Kaiser Permanente Medicaid	$1,496.34
Rate for Payer: Kaiser Permanente Medicare	$1,467.00
Rate for Payer: MDX Hawaii PPO	$2,845.98
Rate for Payer: Ohana Health Plan Medicaid	$1,467.00
Rate for Payer: Ohana Health Plan Medicare	$1,467.00
Rate for Payer: UnitedHealthcare Medicaid	$983.00
Rate for Payer: UnitedHealthcare Medicare	$1,467.00
Rate for Payer: University Health Alliance Commercial	$1,285.53

MRI UE Joint w/ + w/o Contrast Right

Facility

$2,934.00

Service Code	HCPCS 73223 RT
Hospital Charge Code	8211758
Hospital Revenue Code	610
Min. Negotiated Rate	$2,493.90
Max. Negotiated Rate	$2,845.98
Rate for Payer: Cash Price	$1,907.10
Rate for Payer: Health Management Network Commercial	$2,493.90
Rate for Payer: Kaiser Permanente Commercial	$2,640.60
Rate for Payer: MDX Hawaii PPO	$2,845.98

MRI UE Joint w/ + w/o Contrast Right - Report

Professional

Both

$546.00

Service Code	HCPCS 73223 26,RT
Hospital Charge Code	8211760
Hospital Revenue Code	972
Min. Negotiated Rate	$266.19
Max. Negotiated Rate	$1,201.84
Rate for Payer: AlohaCare Medicaid	$266.19
Rate for Payer: Cash Price	$354.90
Rate for Payer: Cash Price	$354.90
Rate for Payer: Hawaii Western Management Group Commercial	$1,201.84
Rate for Payer: Health Management Network Commercial	$464.10
Rate for Payer: Ohana Health Plan Medicaid	$266.19
Rate for Payer: UnitedHealthcare Medicaid	$266.19

MRI UE Non Joint w/ Contrast Lt

Facility

$2,465.00

Service Code	HCPCS 73219 LT
Hospital Charge Code	1169114
Hospital Revenue Code	610
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$2,391.05
Rate for Payer: AlohaCare Medicaid	$1,232.50
Rate for Payer: AlohaCare Medicare	$1,232.50
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Devoted Health Medicare	$1,355.75
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,232.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,341.75
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Humana Medicare	$1,232.50
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: Kaiser Permanente Medicaid	$1,257.15
Rate for Payer: Kaiser Permanente Medicare	$1,232.50
Rate for Payer: MDX Hawaii PPO	$2,391.05
Rate for Payer: Ohana Health Plan Medicaid	$1,232.50
Rate for Payer: Ohana Health Plan Medicare	$1,232.50
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$1,232.50
Rate for Payer: University Health Alliance Commercial	$974.25

MRI UE Non Joint w/ Contrast Lt

Facility

$2,465.00

Service Code	HCPCS 73219 LT
Hospital Charge Code	1169114
Hospital Revenue Code	610
Min. Negotiated Rate	$2,095.25
Max. Negotiated Rate	$2,391.05
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: MDX Hawaii PPO	$2,391.05

MRI UE Non Joint w/ Contrast Lt - Report

Professional

Both

$469.00

Service Code	HCPCS 73219 26,LT
Hospital Charge Code	631368
Hospital Revenue Code	972
Min. Negotiated Rate	$228.65
Max. Negotiated Rate	$398.65
Rate for Payer: AlohaCare Medicaid	$228.65
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Ohana Health Plan Medicaid	$228.65
Rate for Payer: UnitedHealthcare Medicaid	$228.65

MRI UE Non Joint w/ Contrast Rt

Facility

$2,465.00

Service Code	HCPCS 73219 RT
Hospital Charge Code	1169116
Hospital Revenue Code	610
Min. Negotiated Rate	$2,095.25
Max. Negotiated Rate	$2,391.05
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: MDX Hawaii PPO	$2,391.05

MRI UE Non Joint w/ Contrast Rt

Facility

$2,465.00

Service Code	HCPCS 73219 RT
Hospital Charge Code	1169116
Hospital Revenue Code	610
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$2,391.05
Rate for Payer: AlohaCare Medicaid	$1,232.50
Rate for Payer: AlohaCare Medicare	$1,232.50
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Cash Price	$1,602.25
Rate for Payer: Devoted Health Medicare	$1,355.75
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1,232.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$2,341.75
Rate for Payer: Health Management Network Commercial	$2,095.25
Rate for Payer: Humana Medicare	$1,232.50
Rate for Payer: Kaiser Permanente Commercial	$2,218.50
Rate for Payer: Kaiser Permanente Medicaid	$1,257.15
Rate for Payer: Kaiser Permanente Medicare	$1,232.50
Rate for Payer: MDX Hawaii PPO	$2,391.05
Rate for Payer: Ohana Health Plan Medicaid	$1,232.50
Rate for Payer: Ohana Health Plan Medicare	$1,232.50
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$1,232.50
Rate for Payer: University Health Alliance Commercial	$974.25

MRI UE Non Joint w/ Contrast Rt - Report

Professional

Both

$469.00

Service Code	HCPCS 73219 26,RT
Hospital Charge Code	631381
Hospital Revenue Code	972
Min. Negotiated Rate	$228.65
Max. Negotiated Rate	$398.65
Rate for Payer: AlohaCare Medicaid	$228.65
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Ohana Health Plan Medicaid	$228.65
Rate for Payer: UnitedHealthcare Medicaid	$228.65

MRI UE Non Joint w/o Contrast Lt

Facility

$2,322.00

Service Code	HCPCS 73218 LT
Hospital Charge Code	1169120
Hospital Revenue Code	610
Min. Negotiated Rate	$1,973.70
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: MDX Hawaii PPO	$2,252.34

MRI UE Non Joint w/o Contrast Lt

Facility

$2,322.00

Service Code	HCPCS 73218 LT
Hospital Charge Code	1169120
Hospital Revenue Code	610
Min. Negotiated Rate	$318.66
Max. Negotiated Rate	$2,252.34
Rate for Payer: AlohaCare Medicaid	$1,161.00
Rate for Payer: AlohaCare Medicare	$1,161.00
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Devoted Health Medicare	$1,277.10
Rate for Payer: Hawaii Medical Service Association ABD	$318.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1,161.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$396.79
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.90
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Humana Medicare	$1,161.00
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: Kaiser Permanente Medicare	$1,161.00
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: Ohana Health Plan Medicaid	$1,161.00
Rate for Payer: Ohana Health Plan Medicare	$1,161.00
Rate for Payer: UnitedHealthcare Medicaid	$318.66
Rate for Payer: UnitedHealthcare Medicare	$1,161.00
Rate for Payer: University Health Alliance Commercial	$837.87

MRI UE Non Joint w/o Contrast Lt - Report

Professional

Both

$415.00

Service Code	HCPCS 73218 26,LT
Hospital Charge Code	631403
Hospital Revenue Code	972
Min. Negotiated Rate	$209.83
Max. Negotiated Rate	$556.53
Rate for Payer: AlohaCare Medicaid	$209.83
Rate for Payer: Cash Price	$269.75
Rate for Payer: Cash Price	$269.75
Rate for Payer: Hawaii Western Management Group Commercial	$556.53
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Ohana Health Plan Medicaid	$209.83
Rate for Payer: UnitedHealthcare Medicaid	$209.83

MRI UE Non Joint w/o Contrast Rt

Facility

$2,322.00

Service Code	HCPCS 73218 RT
Hospital Charge Code	1169122
Hospital Revenue Code	610
Min. Negotiated Rate	$318.66
Max. Negotiated Rate	$2,252.34
Rate for Payer: AlohaCare Medicaid	$1,161.00
Rate for Payer: AlohaCare Medicare	$1,161.00
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Devoted Health Medicare	$1,277.10
Rate for Payer: Hawaii Medical Service Association ABD	$318.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1,161.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$396.79
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.90
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Humana Medicare	$1,161.00
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: Kaiser Permanente Medicare	$1,161.00
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: Ohana Health Plan Medicaid	$1,161.00
Rate for Payer: Ohana Health Plan Medicare	$1,161.00
Rate for Payer: UnitedHealthcare Medicaid	$318.66
Rate for Payer: UnitedHealthcare Medicare	$1,161.00
Rate for Payer: University Health Alliance Commercial	$837.87

MRI UE Non Joint w/o Contrast Rt

Facility

$2,322.00

Service Code	HCPCS 73218 RT
Hospital Charge Code	1169122
Hospital Revenue Code	610
Min. Negotiated Rate	$1,973.70
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: MDX Hawaii PPO	$2,252.34

MRI UE Non Joint w/o Contrast Rt - Report

Professional

Both

$415.00

Service Code	HCPCS 73218 26,RT
Hospital Charge Code	631410
Hospital Revenue Code	972
Min. Negotiated Rate	$209.83
Max. Negotiated Rate	$556.53
Rate for Payer: AlohaCare Medicaid	$209.83
Rate for Payer: Cash Price	$269.75
Rate for Payer: Cash Price	$269.75
Rate for Payer: Hawaii Western Management Group Commercial	$556.53
Rate for Payer: Health Management Network Commercial	$352.75
Rate for Payer: Ohana Health Plan Medicaid	$209.83
Rate for Payer: UnitedHealthcare Medicaid	$209.83

MRI UE Non Joint w/ + w/o Contrast Lt

Facility

$2,524.00

Service Code	HCPCS 73220 LT
Hospital Charge Code	1169108
Hospital Revenue Code	610
Min. Negotiated Rate	$645.58
Max. Negotiated Rate	$2,448.28
Rate for Payer: AlohaCare Medicaid	$1,262.00
Rate for Payer: AlohaCare Medicare	$1,262.00
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Devoted Health Medicare	$1,388.20
Rate for Payer: Hawaii Medical Service Association ABD	$645.58
Rate for Payer: Hawaii Medical Service Association Medicare	$1,262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$880.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,397.80
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Humana Medicare	$1,262.00
Rate for Payer: Kaiser Permanente Commercial	$2,271.60
Rate for Payer: Kaiser Permanente Medicaid	$1,287.24
Rate for Payer: Kaiser Permanente Medicare	$1,262.00
Rate for Payer: MDX Hawaii PPO	$2,448.28
Rate for Payer: Ohana Health Plan Medicaid	$1,262.00
Rate for Payer: Ohana Health Plan Medicare	$1,262.00
Rate for Payer: UnitedHealthcare Medicaid	$645.58
Rate for Payer: UnitedHealthcare Medicare	$1,262.00
Rate for Payer: University Health Alliance Commercial	$1,286.62

MRI UE Non Joint w/ + w/o Contrast Lt

Facility

$2,524.00

Service Code	HCPCS 73220 LT
Hospital Charge Code	1169108
Hospital Revenue Code	610
Min. Negotiated Rate	$2,145.40
Max. Negotiated Rate	$2,448.28
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Kaiser Permanente Commercial	$2,271.60
Rate for Payer: MDX Hawaii PPO	$2,448.28

MRI UE Non Joint w/ + w/o Contrast Lt - Report

Professional

Both

$578.00

Service Code	HCPCS 73220 26,LT
Hospital Charge Code	631357
Hospital Revenue Code	972
Min. Negotiated Rate	$282.25
Max. Negotiated Rate	$574.09
Rate for Payer: AlohaCare Medicaid	$282.25
Rate for Payer: Cash Price	$375.70
Rate for Payer: Cash Price	$375.70
Rate for Payer: Hawaii Western Management Group Commercial	$574.09
Rate for Payer: Health Management Network Commercial	$491.30
Rate for Payer: Ohana Health Plan Medicaid	$282.25
Rate for Payer: UnitedHealthcare Medicaid	$282.25

MRI UE Non Joint w/ + w/o Contrast Rt

Facility

$2,524.00

Service Code	HCPCS 73220 RT
Hospital Charge Code	1169110
Hospital Revenue Code	610
Min. Negotiated Rate	$2,145.40
Max. Negotiated Rate	$2,448.28
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Kaiser Permanente Commercial	$2,271.60
Rate for Payer: MDX Hawaii PPO	$2,448.28

MRI UE Non Joint w/ + w/o Contrast Rt

Facility

$2,524.00

Service Code	HCPCS 73220 RT
Hospital Charge Code	1169110
Hospital Revenue Code	610
Min. Negotiated Rate	$645.58
Max. Negotiated Rate	$2,448.28
Rate for Payer: AlohaCare Medicaid	$1,262.00
Rate for Payer: AlohaCare Medicare	$1,262.00
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Cash Price	$1,640.60
Rate for Payer: Devoted Health Medicare	$1,388.20
Rate for Payer: Hawaii Medical Service Association ABD	$645.58
Rate for Payer: Hawaii Medical Service Association Medicare	$1,262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$880.75
Rate for Payer: Hawaii Western Management Group Commercial	$2,397.80
Rate for Payer: Health Management Network Commercial	$2,145.40
Rate for Payer: Humana Medicare	$1,262.00
Rate for Payer: Kaiser Permanente Commercial	$2,271.60
Rate for Payer: Kaiser Permanente Medicaid	$1,287.24
Rate for Payer: Kaiser Permanente Medicare	$1,262.00
Rate for Payer: MDX Hawaii PPO	$2,448.28
Rate for Payer: Ohana Health Plan Medicaid	$1,262.00
Rate for Payer: Ohana Health Plan Medicare	$1,262.00
Rate for Payer: UnitedHealthcare Medicaid	$645.58
Rate for Payer: UnitedHealthcare Medicare	$1,262.00
Rate for Payer: University Health Alliance Commercial	$1,286.62

MRI UE Non Joint w/ + w/o Contrast Rt - Report

Professional

Both

$578.00

Service Code	HCPCS 73220 26,RT
Hospital Charge Code	631361
Hospital Revenue Code	972
Min. Negotiated Rate	$282.25
Max. Negotiated Rate	$574.09
Rate for Payer: AlohaCare Medicaid	$282.25
Rate for Payer: Cash Price	$375.70
Rate for Payer: Cash Price	$375.70
Rate for Payer: Hawaii Western Management Group Commercial	$574.09
Rate for Payer: Health Management Network Commercial	$491.30
Rate for Payer: Ohana Health Plan Medicaid	$282.25
Rate for Payer: UnitedHealthcare Medicaid	$282.25

MRI Upper Extremity w/o Contrast Left

Facility

$2,322.00

Service Code	HCPCS 73218 LT
Hospital Charge Code	8207933
Hospital Revenue Code	610
Min. Negotiated Rate	$318.66
Max. Negotiated Rate	$2,252.34
Rate for Payer: AlohaCare Medicaid	$1,161.00
Rate for Payer: AlohaCare Medicare	$1,161.00
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Devoted Health Medicare	$1,277.10
Rate for Payer: Hawaii Medical Service Association ABD	$318.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1,161.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$396.79
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.90
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Humana Medicare	$1,161.00
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: Kaiser Permanente Medicare	$1,161.00
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: Ohana Health Plan Medicaid	$1,161.00
Rate for Payer: Ohana Health Plan Medicare	$1,161.00
Rate for Payer: UnitedHealthcare Medicaid	$318.66
Rate for Payer: UnitedHealthcare Medicare	$1,161.00
Rate for Payer: University Health Alliance Commercial	$837.87

MRI Upper Extremity w/o Contrast Left

Facility

$2,322.00

Service Code	HCPCS 73218 LT
Hospital Charge Code	8207933
Hospital Revenue Code	610
Min. Negotiated Rate	$1,973.70
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: MDX Hawaii PPO	$2,252.34

MRI Upper Extremity w/o Contrast Right

Facility

$2,322.00

Service Code	HCPCS 73218 RT
Hospital Charge Code	8207936
Hospital Revenue Code	610
Min. Negotiated Rate	$318.66
Max. Negotiated Rate	$2,252.34
Rate for Payer: AlohaCare Medicaid	$1,161.00
Rate for Payer: AlohaCare Medicare	$1,161.00
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Devoted Health Medicare	$1,277.10
Rate for Payer: Hawaii Medical Service Association ABD	$318.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1,161.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$396.79
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.90
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Humana Medicare	$1,161.00
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: Kaiser Permanente Medicare	$1,161.00
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: Ohana Health Plan Medicaid	$1,161.00
Rate for Payer: Ohana Health Plan Medicare	$1,161.00
Rate for Payer: UnitedHealthcare Medicaid	$318.66
Rate for Payer: UnitedHealthcare Medicare	$1,161.00
Rate for Payer: University Health Alliance Commercial	$837.87

Know your out-of-pocket cost for care.

All Charges