Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

74178 - add on report

Professional

Both

$582.00

Service Code	HCPCS 74178
Hospital Charge Code	12221353
Hospital Revenue Code	972
Min. Negotiated Rate	$232.99
Max. Negotiated Rate	$499.94
Rate for Payer: AlohaCare Medicaid	$232.99
Rate for Payer: AlohaCare Medicare	$372.56
Rate for Payer: Cash Price	$378.30
Rate for Payer: Cash Price	$378.30
Rate for Payer: Devoted Health Medicare	$409.82
Rate for Payer: Hawaii Medical Service Association Medicare	$372.56
Rate for Payer: Hawaii Western Management Group Commercial	$499.94
Rate for Payer: Health Management Network Commercial	$494.70
Rate for Payer: Kaiser Permanente Commercial	$409.82
Rate for Payer: Kaiser Permanente Medicaid	$409.82
Rate for Payer: Kaiser Permanente Medicare	$409.82
Rate for Payer: Ohana Health Plan Medicaid	$232.99
Rate for Payer: Ohana Health Plan Medicare	$372.56
Rate for Payer: UnitedHealthcare Medicaid	$232.99
Rate for Payer: UnitedHealthcare Medicare	$372.56

74246 RADEX GI UPR C+ +-GLUC/DLYD FLMS W/O KUB ProFee

Professional

Both

$244.00

Service Code	HCPCS 74246 26
Hospital Charge Code	8102804
Hospital Revenue Code	972
Min. Negotiated Rate	$42.51
Max. Negotiated Rate	$207.40
Rate for Payer: AlohaCare Medicaid	$92.31
Rate for Payer: AlohaCare Medicare	$42.51
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$46.76
Rate for Payer: Hawaii Medical Service Association Medicare	$42.51
Rate for Payer: Hawaii Western Management Group Commercial	$110.48
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$46.76
Rate for Payer: Kaiser Permanente Medicaid	$46.76
Rate for Payer: Kaiser Permanente Medicare	$46.76
Rate for Payer: Ohana Health Plan Medicaid	$92.31
Rate for Payer: Ohana Health Plan Medicare	$42.51
Rate for Payer: UnitedHealthcare Medicaid	$92.31
Rate for Payer: UnitedHealthcare Medicare	$42.51

74248 X-Ray Sm Int F-Thru Std Rad ProFee

Professional

Both

$111.00

Service Code	HCPCS 74248 26
Hospital Charge Code	8881998
Hospital Revenue Code	972
Min. Negotiated Rate	$32.60
Max. Negotiated Rate	$94.35
Rate for Payer: AlohaCare Medicaid	$54.01
Rate for Payer: AlohaCare Medicare	$32.60
Rate for Payer: Cash Price	$72.15
Rate for Payer: Cash Price	$72.15
Rate for Payer: Devoted Health Medicare	$35.86
Rate for Payer: Hawaii Medical Service Association Medicare	$32.60
Rate for Payer: Hawaii Western Management Group Commercial	$91.74
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$35.86
Rate for Payer: Kaiser Permanente Medicaid	$35.86
Rate for Payer: Kaiser Permanente Medicare	$35.86
Rate for Payer: Ohana Health Plan Medicaid	$54.01
Rate for Payer: Ohana Health Plan Medicare	$32.60
Rate for Payer: UnitedHealthcare Medicaid	$54.01
Rate for Payer: UnitedHealthcare Medicare	$32.60

74450 URETHROCSTOGRAPY RTRGR RS&I ProFee

Professional

Both

$332.00

Service Code	HCPCS 74450 26
Hospital Charge Code	8102837
Hospital Revenue Code	972
Min. Negotiated Rate	$15.63
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$61.21
Rate for Payer: AlohaCare Medicare	$15.63
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$17.19
Rate for Payer: Hawaii Medical Service Association Medicare	$15.63
Rate for Payer: Hawaii Western Management Group Commercial	$82.41
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$17.19
Rate for Payer: Kaiser Permanente Medicaid	$17.19
Rate for Payer: Kaiser Permanente Medicare	$17.19
Rate for Payer: Ohana Health Plan Medicaid	$61.21
Rate for Payer: Ohana Health Plan Medicare	$15.63
Rate for Payer: UnitedHealthcare Medicaid	$61.21
Rate for Payer: UnitedHealthcare Medicare	$15.63

74450 XR URETHROCYSTOGRAPHY RETROGR

Facility

$1,234.00

Service Code	HCPCS 74450
Hospital Charge Code	9929652
Hospital Revenue Code	320
Min. Negotiated Rate	$48.23
Max. Negotiated Rate	$1,196.98
Rate for Payer: AlohaCare Medicaid	$617.00
Rate for Payer: AlohaCare Medicare	$617.00
Rate for Payer: Cash Price	$802.10
Rate for Payer: Cash Price	$802.10
Rate for Payer: Devoted Health Medicare	$678.70
Rate for Payer: Hawaii Medical Service Association ABD	$48.23
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$617.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.32
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Humana Medicare	$617.00
Rate for Payer: Kaiser Permanente Commercial	$1,110.60
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: Kaiser Permanente Medicare	$617.00
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: Ohana Health Plan Medicaid	$617.00
Rate for Payer: Ohana Health Plan Medicare	$617.00
Rate for Payer: UnitedHealthcare Medicaid	$48.23
Rate for Payer: UnitedHealthcare Medicare	$617.00
Rate for Payer: University Health Alliance Commercial	$899.46

74450 XR URETHROCYSTOGRAPHY RETROGR

Facility

$1,234.00

Service Code	HCPCS 74450
Hospital Charge Code	9929652
Hospital Revenue Code	320
Min. Negotiated Rate	$1,048.90
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$802.10
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Kaiser Permanente Commercial	$1,110.60
Rate for Payer: MDX Hawaii PPO	$1,196.98

75989 US Perc Drainage Abscess

Facility

$1,442.00

Service Code	HCPCS 75989
Hospital Charge Code	8280921
Hospital Revenue Code	402
Min. Negotiated Rate	$1,225.70
Max. Negotiated Rate	$1,398.74
Rate for Payer: Cash Price	$937.30
Rate for Payer: Health Management Network Commercial	$1,225.70
Rate for Payer: Kaiser Permanente Commercial	$1,297.80
Rate for Payer: MDX Hawaii PPO	$1,398.74

75989 US Perc Drainage Abscess

Facility

$1,442.00

Service Code	HCPCS 75989
Hospital Charge Code	8280921
Hospital Revenue Code	402
Min. Negotiated Rate	$103.94
Max. Negotiated Rate	$1,398.74
Rate for Payer: AlohaCare Medicaid	$721.00
Rate for Payer: AlohaCare Medicare	$721.00
Rate for Payer: Cash Price	$937.30
Rate for Payer: Cash Price	$937.30
Rate for Payer: Devoted Health Medicare	$793.10
Rate for Payer: Hawaii Medical Service Association ABD	$103.94
Rate for Payer: Hawaii Medical Service Association Medicare	$721.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$112.58
Rate for Payer: Hawaii Western Management Group Commercial	$1,369.90
Rate for Payer: Health Management Network Commercial	$1,225.70
Rate for Payer: Humana Medicare	$721.00
Rate for Payer: Kaiser Permanente Commercial	$1,297.80
Rate for Payer: Kaiser Permanente Medicaid	$735.42
Rate for Payer: Kaiser Permanente Medicare	$721.00
Rate for Payer: MDX Hawaii PPO	$1,398.74
Rate for Payer: Ohana Health Plan Medicaid	$721.00
Rate for Payer: Ohana Health Plan Medicare	$721.00
Rate for Payer: UnitedHealthcare Medicaid	$103.94
Rate for Payer: UnitedHealthcare Medicare	$721.00
Rate for Payer: University Health Alliance Commercial	$317.64

76000 FLUOR SPX <1 HR PHYS TM OTH/THN 71023/71034 ProFee

Professional

Both

$332.00

Service Code	HCPCS 76000 26
Hospital Charge Code	8102936
Hospital Revenue Code	972
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$28.01
Rate for Payer: AlohaCare Medicare	$15.54
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$17.09
Rate for Payer: Hawaii Medical Service Association Medicare	$15.54
Rate for Payer: Hawaii Western Management Group Commercial	$41.25
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$17.09
Rate for Payer: Kaiser Permanente Medicaid	$17.09
Rate for Payer: Kaiser Permanente Medicare	$17.09
Rate for Payer: Ohana Health Plan Medicaid	$28.01
Rate for Payer: Ohana Health Plan Medicare	$15.54
Rate for Payer: UnitedHealthcare Medicaid	$28.01
Rate for Payer: UnitedHealthcare Medicare	$15.54

76380 CT LMTD/LOCLZD F-UP STD ProFee

Professional

Both

$136.00

Service Code	HCPCS 76380 26
Hospital Charge Code	8102948
Hospital Revenue Code	972
Min. Negotiated Rate	$45.19
Max. Negotiated Rate	$207.33
Rate for Payer: AlohaCare Medicaid	$88.51
Rate for Payer: AlohaCare Medicare	$45.19
Rate for Payer: Cash Price	$88.40
Rate for Payer: Cash Price	$88.40
Rate for Payer: Devoted Health Medicare	$49.71
Rate for Payer: Hawaii Medical Service Association Medicare	$45.19
Rate for Payer: Hawaii Western Management Group Commercial	$207.33
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$49.71
Rate for Payer: Kaiser Permanente Medicaid	$49.71
Rate for Payer: Kaiser Permanente Medicare	$49.71
Rate for Payer: Ohana Health Plan Medicaid	$88.51
Rate for Payer: Ohana Health Plan Medicare	$45.19
Rate for Payer: UnitedHealthcare Medicaid	$88.51
Rate for Payer: UnitedHealthcare Medicare	$45.19

76512 POCUS OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN

Facility

$458.00

Service Code	HCPCS 76512
Hospital Charge Code	12133642
Hospital Revenue Code	402
Min. Negotiated Rate	$47.80
Max. Negotiated Rate	$444.26
Rate for Payer: AlohaCare Medicaid	$229.00
Rate for Payer: AlohaCare Medicare	$229.00
Rate for Payer: Cash Price	$297.70
Rate for Payer: Cash Price	$297.70
Rate for Payer: Devoted Health Medicare	$251.90
Rate for Payer: Hawaii Medical Service Association ABD	$47.80
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$229.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$74.09
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$389.30
Rate for Payer: Humana Medicare	$229.00
Rate for Payer: Kaiser Permanente Commercial	$412.20
Rate for Payer: Kaiser Permanente Medicaid	$233.58
Rate for Payer: Kaiser Permanente Medicare	$229.00
Rate for Payer: MDX Hawaii PPO	$444.26
Rate for Payer: Ohana Health Plan Medicaid	$229.00
Rate for Payer: Ohana Health Plan Medicare	$229.00
Rate for Payer: UnitedHealthcare Medicaid	$47.80
Rate for Payer: UnitedHealthcare Medicare	$229.00
Rate for Payer: University Health Alliance Commercial	$200.08

76512 POCUS OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN

Facility

$458.00

Service Code	HCPCS 76512
Hospital Charge Code	12133642
Hospital Revenue Code	402
Min. Negotiated Rate	$389.30
Max. Negotiated Rate	$444.26
Rate for Payer: Cash Price	$297.70
Rate for Payer: Health Management Network Commercial	$389.30
Rate for Payer: Kaiser Permanente Commercial	$412.20
Rate for Payer: MDX Hawaii PPO	$444.26

76512 POCUS OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN Profee

Professional

Both

$53.00

Service Code	HCPCS 76512
Hospital Charge Code	12133787
Hospital Revenue Code	972
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$104.92
Rate for Payer: AlohaCare Medicaid	$31.14
Rate for Payer: AlohaCare Medicare	$52.56
Rate for Payer: Cash Price	$34.45
Rate for Payer: Cash Price	$34.45
Rate for Payer: Devoted Health Medicare	$57.82
Rate for Payer: Hawaii Medical Service Association Medicare	$52.56
Rate for Payer: Hawaii Western Management Group Commercial	$104.92
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Kaiser Permanente Commercial	$57.82
Rate for Payer: Kaiser Permanente Medicaid	$57.82
Rate for Payer: Kaiser Permanente Medicare	$57.82
Rate for Payer: Ohana Health Plan Medicaid	$31.14
Rate for Payer: Ohana Health Plan Medicare	$52.56
Rate for Payer: UnitedHealthcare Medicaid	$31.14
Rate for Payer: UnitedHealthcare Medicare	$52.56

76536 US Soft Tissues Head / Neck

Facility

$808.00

Service Code	HCPCS 76536
Hospital Charge Code	8280920
Hospital Revenue Code	402
Min. Negotiated Rate	$686.80
Max. Negotiated Rate	$783.76
Rate for Payer: Cash Price	$525.20
Rate for Payer: Health Management Network Commercial	$686.80
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: MDX Hawaii PPO	$783.76

76536 US Soft Tissues Head / Neck

Facility

$808.00

Service Code	HCPCS 76536
Hospital Charge Code	8280920
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$783.76
Rate for Payer: AlohaCare Medicaid	$404.00
Rate for Payer: AlohaCare Medicare	$404.00
Rate for Payer: Cash Price	$525.20
Rate for Payer: Cash Price	$525.20
Rate for Payer: Devoted Health Medicare	$444.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$404.00
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	$686.80
Rate for Payer: Humana Medicare	$404.00
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: Kaiser Permanente Medicaid	$412.08
Rate for Payer: Kaiser Permanente Medicare	$404.00
Rate for Payer: MDX Hawaii PPO	$783.76
Rate for Payer: Ohana Health Plan Medicaid	$404.00
Rate for Payer: Ohana Health Plan Medicare	$404.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$404.00
Rate for Payer: University Health Alliance Commercial	$211.12

76604 US Chest

Facility

$833.00

Service Code	HCPCS 76604
Hospital Charge Code	9887459
Hospital Revenue Code	402
Min. Negotiated Rate	$708.05
Max. Negotiated Rate	$808.01
Rate for Payer: Cash Price	$541.45
Rate for Payer: Health Management Network Commercial	$708.05
Rate for Payer: Kaiser Permanente Commercial	$749.70
Rate for Payer: MDX Hawaii PPO	$808.01

76604 US Chest

Facility

$833.00

Service Code	HCPCS 76604
Hospital Charge Code	9887459
Hospital Revenue Code	402
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$808.01
Rate for Payer: AlohaCare Medicaid	$416.50
Rate for Payer: AlohaCare Medicare	$416.50
Rate for Payer: Cash Price	$541.45
Rate for Payer: Cash Price	$541.45
Rate for Payer: Devoted Health Medicare	$458.15
Rate for Payer: Hawaii Medical Service Association ABD	$42.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$416.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.81
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$708.05
Rate for Payer: Humana Medicare	$416.50
Rate for Payer: Kaiser Permanente Commercial	$749.70
Rate for Payer: Kaiser Permanente Medicaid	$424.83
Rate for Payer: Kaiser Permanente Medicare	$416.50
Rate for Payer: MDX Hawaii PPO	$808.01
Rate for Payer: Ohana Health Plan Medicaid	$416.50
Rate for Payer: Ohana Health Plan Medicare	$416.50
Rate for Payer: UnitedHealthcare Medicaid	$42.98
Rate for Payer: UnitedHealthcare Medicare	$416.50
Rate for Payer: University Health Alliance Commercial	$171.44

76604 US Chest Bedside POC

Facility

$833.00

Service Code	HCPCS 76604
Hospital Charge Code	8279085
Hospital Revenue Code	402
Min. Negotiated Rate	$708.05
Max. Negotiated Rate	$808.01
Rate for Payer: Cash Price	$541.45
Rate for Payer: Health Management Network Commercial	$708.05
Rate for Payer: Kaiser Permanente Commercial	$749.70
Rate for Payer: MDX Hawaii PPO	$808.01

76604 US Chest Bedside POC

Facility

$833.00

Service Code	HCPCS 76604
Hospital Charge Code	8279085
Hospital Revenue Code	402
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$808.01
Rate for Payer: AlohaCare Medicaid	$416.50
Rate for Payer: AlohaCare Medicare	$416.50
Rate for Payer: Cash Price	$541.45
Rate for Payer: Cash Price	$541.45
Rate for Payer: Devoted Health Medicare	$458.15
Rate for Payer: Hawaii Medical Service Association ABD	$42.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$416.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.81
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$708.05
Rate for Payer: Humana Medicare	$416.50
Rate for Payer: Kaiser Permanente Commercial	$749.70
Rate for Payer: Kaiser Permanente Medicaid	$424.83
Rate for Payer: Kaiser Permanente Medicare	$416.50
Rate for Payer: MDX Hawaii PPO	$808.01
Rate for Payer: Ohana Health Plan Medicaid	$416.50
Rate for Payer: Ohana Health Plan Medicare	$416.50
Rate for Payer: UnitedHealthcare Medicaid	$42.98
Rate for Payer: UnitedHealthcare Medicare	$416.50
Rate for Payer: University Health Alliance Commercial	$171.44

76604 US CHEST REAL TIME W/IMAGE DOCUMENTATION

Professional

Both

$145.00

Service Code	HCPCS 76604
Hospital Charge Code	9301825
Hospital Revenue Code	972
Min. Negotiated Rate	$37.02
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$37.02
Rate for Payer: AlohaCare Medicare	$65.91
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$72.50
Rate for Payer: Hawaii Medical Service Association Medicare	$65.91
Rate for Payer: Hawaii Western Management Group Commercial	$87.58
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$72.50
Rate for Payer: Kaiser Permanente Medicaid	$72.50
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: Ohana Health Plan Medicaid	$37.02
Rate for Payer: Ohana Health Plan Medicare	$65.91
Rate for Payer: UnitedHealthcare Medicaid	$37.02
Rate for Payer: UnitedHealthcare Medicare	$65.91

76705 US Abdomen/Lower Back Limited

Facility

$708.00

Service Code	HCPCS 76705
Hospital Charge Code	1169569
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$354.00
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$389.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$354.00
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	$601.80
Rate for Payer: Humana Medicare	$354.00
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$354.00
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$354.00
Rate for Payer: Ohana Health Plan Medicare	$354.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$354.00
Rate for Payer: University Health Alliance Commercial	$200.93

76705 US Abdomen/Lower Back Limited

Facility

$808.00

Service Code	HCPCS 76705
Hospital Charge Code	8280904
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$783.76
Rate for Payer: AlohaCare Medicaid	$404.00
Rate for Payer: AlohaCare Medicare	$404.00
Rate for Payer: Cash Price	$525.20
Rate for Payer: Cash Price	$525.20
Rate for Payer: Devoted Health Medicare	$444.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$404.00
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	$686.80
Rate for Payer: Humana Medicare	$404.00
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: Kaiser Permanente Medicaid	$412.08
Rate for Payer: Kaiser Permanente Medicare	$404.00
Rate for Payer: MDX Hawaii PPO	$783.76
Rate for Payer: Ohana Health Plan Medicaid	$404.00
Rate for Payer: Ohana Health Plan Medicare	$404.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$404.00
Rate for Payer: University Health Alliance Commercial	$200.93

76705 US Abdomen/Lower Back Limited

Facility

$808.00

Service Code	HCPCS 76705
Hospital Charge Code	8280904
Hospital Revenue Code	402
Min. Negotiated Rate	$686.80
Max. Negotiated Rate	$783.76
Rate for Payer: Cash Price	$525.20
Rate for Payer: Health Management Network Commercial	$686.80
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: MDX Hawaii PPO	$783.76

76705 US Abdomen/Lower Back Limited

Facility

$708.00

Service Code	HCPCS 76705
Hospital Charge Code	1169569
Hospital Revenue Code	402
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

76770 US Retroperitoneal Complete

Facility

$858.00

Service Code	HCPCS 76770
Hospital Charge Code	8280902
Hospital Revenue Code	402
Min. Negotiated Rate	$64.94
Max. Negotiated Rate	$832.26
Rate for Payer: AlohaCare Medicaid	$429.00
Rate for Payer: AlohaCare Medicare	$429.00
Rate for Payer: Cash Price	$557.70
Rate for Payer: Cash Price	$557.70
Rate for Payer: Devoted Health Medicare	$471.90
Rate for Payer: Hawaii Medical Service Association ABD	$64.94
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$429.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$70.56
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: Humana Medicare	$429.00
Rate for Payer: Kaiser Permanente Commercial	$772.20
Rate for Payer: Kaiser Permanente Medicaid	$437.58
Rate for Payer: Kaiser Permanente Medicare	$429.00
Rate for Payer: MDX Hawaii PPO	$832.26
Rate for Payer: Ohana Health Plan Medicaid	$429.00
Rate for Payer: Ohana Health Plan Medicare	$429.00
Rate for Payer: UnitedHealthcare Medicaid	$64.94
Rate for Payer: UnitedHealthcare Medicare	$429.00
Rate for Payer: University Health Alliance Commercial	$258.91

Know your out-of-pocket cost for care.

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