Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

US Lower Ext Arterial Duplex Right

Facility

$740.00

Service Code	HCPCS 93926 RT
Hospital Charge Code	1169763
Hospital Revenue Code	921
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

US Lower Ext Arterial Duplex Right - Report

Professional

Both

$145.00

Service Code	HCPCS 93926 26,RT
Hospital Charge Code	631047
Hospital Revenue Code	972
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$161.18
Rate for Payer: AlohaCare Medicaid	$161.18
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$131.13
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$161.18
Rate for Payer: UnitedHealthcare Medicaid	$161.18

US Lower Extrem Non Vasc Comp LT POC

Facility

$758.00

Service Code	HCPCS 76881
Hospital Charge Code	10234947
Hospital Revenue Code	320
Min. Negotiated Rate	$50.90
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$61.93
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$61.93
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$246.33

US Lower Extrem Non Vasc Comp LT POC

Facility

$758.00

Service Code	HCPCS 76881
Hospital Charge Code	10234947
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Lower Extrem Non Vasc Comp RT POC

Facility

$758.00

Service Code	HCPCS 76881
Hospital Charge Code	10234948
Hospital Revenue Code	320
Min. Negotiated Rate	$50.90
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$61.93
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$61.93
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$246.33

US Lower Extrem Non Vasc Comp RT POC

Facility

$758.00

Service Code	HCPCS 76881
Hospital Charge Code	10234948
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Lower Extrem Non Vasc LT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234949
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Lower Extrem Non Vasc LT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234949
Hospital Revenue Code	320
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.72
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$60.62

US Lower Extrem Non Vasc RT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234950
Hospital Revenue Code	320
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.72
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$60.62

US Lower Extrem Non Vasc RT POC

Facility

$758.00

Service Code	HCPCS 76882
Hospital Charge Code	10234950
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Lower Extrem Venous Duplex LT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10234944
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Lower Extrem Venous Duplex LT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10234944
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$554.69

US Lower Extrem Venous Duplex RT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10234945
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$554.69

US Lower Extrem Venous Duplex RT POC

Facility

$761.00

Service Code	HCPCS 93971
Hospital Charge Code	10234945
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Lower Ext Venous Duplex Bilateral

Facility

$1,527.00

Service Code	HCPCS 93970
Hospital Charge Code	1169769
Hospital Revenue Code	921
Min. Negotiated Rate	$139.85
Max. Negotiated Rate	$1,481.19
Rate for Payer: AlohaCare Medicaid	$763.50
Rate for Payer: AlohaCare Medicare	$763.50
Rate for Payer: Cash Price	$992.55
Rate for Payer: Cash Price	$992.55
Rate for Payer: Devoted Health Medicare	$839.85
Rate for Payer: Hawaii Medical Service Association ABD	$139.85
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$763.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$160.42
Rate for Payer: Hawaii Western Management Group Commercial	$1,450.65
Rate for Payer: Health Management Network Commercial	$1,297.95
Rate for Payer: Humana Medicare	$763.50
Rate for Payer: Kaiser Permanente Commercial	$1,374.30
Rate for Payer: Kaiser Permanente Medicaid	$778.77
Rate for Payer: Kaiser Permanente Medicare	$763.50
Rate for Payer: MDX Hawaii PPO	$1,481.19
Rate for Payer: Ohana Health Plan Medicaid	$763.50
Rate for Payer: Ohana Health Plan Medicare	$763.50
Rate for Payer: UnitedHealthcare Medicaid	$139.85
Rate for Payer: UnitedHealthcare Medicare	$763.50
Rate for Payer: University Health Alliance Commercial	$1,113.03

US Lower Ext Venous Duplex Bilateral

Facility

$1,527.00

Service Code	HCPCS 93970
Hospital Charge Code	1169769
Hospital Revenue Code	921
Min. Negotiated Rate	$1,297.95
Max. Negotiated Rate	$1,481.19
Rate for Payer: Cash Price	$992.55
Rate for Payer: Health Management Network Commercial	$1,297.95
Rate for Payer: Kaiser Permanente Commercial	$1,374.30
Rate for Payer: MDX Hawaii PPO	$1,481.19

US Lower Ext Venous Duplex Bilateral - Report

Professional

Both

$332.00

Service Code	HCPCS 93970 26
Hospital Charge Code	631030
Hospital Revenue Code	972
Min. Negotiated Rate	$32.23
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$209.33
Rate for Payer: AlohaCare Medicare	$32.23
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$35.45
Rate for Payer: Hawaii Medical Service Association Medicare	$32.23
Rate for Payer: Hawaii Western Management Group Commercial	$161.05
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$35.45
Rate for Payer: Kaiser Permanente Medicaid	$35.45
Rate for Payer: Kaiser Permanente Medicare	$35.45
Rate for Payer: Ohana Health Plan Medicaid	$209.33
Rate for Payer: Ohana Health Plan Medicare	$32.23
Rate for Payer: UnitedHealthcare Medicaid	$209.33
Rate for Payer: UnitedHealthcare Medicare	$32.23

US Lower Ext Venous Duplex Left

Facility

$761.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	1169771
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$554.69

US Lower Ext Venous Duplex Left

Facility

$761.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	1169771
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Lower Ext Venous Duplex Left - Report

Professional

Both

$145.00

Service Code	HCPCS 93971 26,LT
Hospital Charge Code	631025
Hospital Revenue Code	972
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$133.33
Rate for Payer: AlohaCare Medicaid	$133.33
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$130.82
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$133.33
Rate for Payer: UnitedHealthcare Medicaid	$133.33

US Lower Ext Venous Duplex Right

Facility

$761.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	1169773
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$722.95
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$554.69

US Lower Ext Venous Duplex Right

Facility

$761.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	1169773
Hospital Revenue Code	921
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Lower Ext Venous Duplex Right - Report

Professional

Both

$145.00

Service Code	HCPCS 93971 26,RT
Hospital Charge Code	631020
Hospital Revenue Code	972
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$133.33
Rate for Payer: AlohaCare Medicaid	$133.33
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$130.82
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$133.33
Rate for Payer: UnitedHealthcare Medicaid	$133.33

US OB < 14 weeks w/ TVS if indicated

Facility

$758.00

Service Code	HCPCS 76801
Hospital Charge Code	1169848
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US OB < 14 weeks w/ TVS if indicated

Facility

$758.00

Service Code	HCPCS 76801
Hospital Charge Code	1169848
Hospital Revenue Code	402
Min. Negotiated Rate	$55.49
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$55.49
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$66.25
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$55.49
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$265.83

Know your out-of-pocket cost for care.

All Charges