Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Ankle Complete 3+ Views Bilateral

Facility

$481.00

Service Code	HCPCS 73610 50
Hospital Charge Code	1169940
Hospital Revenue Code	320
Min. Negotiated Rate	$408.85
Max. Negotiated Rate	$466.57
Rate for Payer: Cash Price	$312.65
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: MDX Hawaii PPO	$466.57

XR Ankle Complete 3+ Views Bilateral - Report

Professional

Both

$66.00

Service Code	HCPCS 73610 26,50
Hospital Charge Code	625723
Hospital Revenue Code	972
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: UnitedHealthcare Medicaid	$24.50

XR Ankle Complete 3+ Views Left

Facility

$481.00

Service Code	HCPCS 73610 LT
Hospital Charge Code	1169942
Hospital Revenue Code	320
Min. Negotiated Rate	$17.34
Max. Negotiated Rate	$466.57
Rate for Payer: AlohaCare Medicaid	$240.50
Rate for Payer: AlohaCare Medicare	$240.50
Rate for Payer: Cash Price	$312.65
Rate for Payer: Cash Price	$312.65
Rate for Payer: Devoted Health Medicare	$264.55
Rate for Payer: Hawaii Medical Service Association ABD	$17.34
Rate for Payer: Hawaii Medical Service Association Medicare	$240.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.95
Rate for Payer: Hawaii Western Management Group Commercial	$456.95
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Humana Medicare	$240.50
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: Kaiser Permanente Medicaid	$245.31
Rate for Payer: Kaiser Permanente Medicare	$240.50
Rate for Payer: MDX Hawaii PPO	$466.57
Rate for Payer: Ohana Health Plan Medicaid	$240.50
Rate for Payer: Ohana Health Plan Medicare	$240.50
Rate for Payer: UnitedHealthcare Medicaid	$17.34
Rate for Payer: UnitedHealthcare Medicare	$240.50
Rate for Payer: University Health Alliance Commercial	$62.59

XR Ankle Complete 3+ Views Left

Facility

$481.00

Service Code	HCPCS 73610 LT
Hospital Charge Code	1169942
Hospital Revenue Code	320
Min. Negotiated Rate	$408.85
Max. Negotiated Rate	$466.57
Rate for Payer: Cash Price	$312.65
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: MDX Hawaii PPO	$466.57

XR Ankle Complete 3+ Views Left - Report

Professional

Both

$66.00

Service Code	HCPCS 73610 26,LT
Hospital Charge Code	625725
Hospital Revenue Code	972
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: UnitedHealthcare Medicaid	$24.50

XR Ankle Complete 3+ Views Right

Facility

$481.00

Service Code	HCPCS 73610 RT
Hospital Charge Code	1169944
Hospital Revenue Code	320
Min. Negotiated Rate	$17.34
Max. Negotiated Rate	$466.57
Rate for Payer: AlohaCare Medicaid	$240.50
Rate for Payer: AlohaCare Medicare	$240.50
Rate for Payer: Cash Price	$312.65
Rate for Payer: Cash Price	$312.65
Rate for Payer: Devoted Health Medicare	$264.55
Rate for Payer: Hawaii Medical Service Association ABD	$17.34
Rate for Payer: Hawaii Medical Service Association Medicare	$240.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.95
Rate for Payer: Hawaii Western Management Group Commercial	$456.95
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Humana Medicare	$240.50
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: Kaiser Permanente Medicaid	$245.31
Rate for Payer: Kaiser Permanente Medicare	$240.50
Rate for Payer: MDX Hawaii PPO	$466.57
Rate for Payer: Ohana Health Plan Medicaid	$240.50
Rate for Payer: Ohana Health Plan Medicare	$240.50
Rate for Payer: UnitedHealthcare Medicaid	$17.34
Rate for Payer: UnitedHealthcare Medicare	$240.50
Rate for Payer: University Health Alliance Commercial	$62.59

XR Ankle Complete 3+ Views Right

Facility

$481.00

Service Code	HCPCS 73610 RT
Hospital Charge Code	1169944
Hospital Revenue Code	320
Min. Negotiated Rate	$408.85
Max. Negotiated Rate	$466.57
Rate for Payer: Cash Price	$312.65
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: MDX Hawaii PPO	$466.57

XR Ankle Complete 3+ Views Right - Report

Professional

Both

$66.00

Service Code	HCPCS 73610 26,RT
Hospital Charge Code	625727
Hospital Revenue Code	972
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: UnitedHealthcare Medicaid	$24.50

XR Arthrogram Ankle SI Left

Facility

$1,520.00

Service Code	HCPCS 73615
Hospital Charge Code	2425392
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Ankle SI Left

Facility

$1,520.00

Service Code	HCPCS 73615
Hospital Charge Code	2425392
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$212.97

XR Arthrogram Ankle SI Right

Facility

$1,520.00

Service Code	HCPCS 73615
Hospital Charge Code	2425395
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$212.97

XR Arthrogram Ankle SI Right

Facility

$1,520.00

Service Code	HCPCS 73615
Hospital Charge Code	2425395
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Elbow Left

Facility

$1,520.00

Service Code	HCPCS 73085
Hospital Charge Code	8127585
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.85

XR Arthrogram Elbow Left

Facility

$1,520.00

Service Code	HCPCS 73085
Hospital Charge Code	8127585
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Elbow Right

Facility

$1,520.00

Service Code	HCPCS 73085
Hospital Charge Code	8127588
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Elbow Right

Facility

$1,520.00

Service Code	HCPCS 73085
Hospital Charge Code	8127588
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.85

XR Arthrogram Hip Left

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127591
Hospital Revenue Code	322
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.57

XR Arthrogram Hip Left

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127591
Hospital Revenue Code	322
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Hip Right

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127594
Hospital Revenue Code	322
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Hip Right

Facility

$1,520.00

Service Code	HCPCS 73525
Hospital Charge Code	8127594
Hospital Revenue Code	322
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$206.57

XR Arthrogram Injection Ankle Left

Facility

$1,520.00

Service Code	HCPCS 73615 LT
Hospital Charge Code	1169950
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$212.97

XR Arthrogram Injection Ankle Left

Facility

$1,520.00

Service Code	HCPCS 73615 LT
Hospital Charge Code	1169950
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Ankle Right

Facility

$1,520.00

Service Code	HCPCS 73615 RT
Hospital Charge Code	1169952
Hospital Revenue Code	320
Min. Negotiated Rate	$69.25
Max. Negotiated Rate	$1,474.40
Rate for Payer: AlohaCare Medicaid	$760.00
Rate for Payer: AlohaCare Medicare	$760.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Cash Price	$988.00
Rate for Payer: Devoted Health Medicare	$836.00
Rate for Payer: Hawaii Medical Service Association ABD	$69.25
Rate for Payer: Hawaii Medical Service Association Medicare	$760.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.32
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Humana Medicare	$760.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: Kaiser Permanente Medicaid	$775.20
Rate for Payer: Kaiser Permanente Medicare	$760.00
Rate for Payer: MDX Hawaii PPO	$1,474.40
Rate for Payer: Ohana Health Plan Medicaid	$760.00
Rate for Payer: Ohana Health Plan Medicare	$760.00
Rate for Payer: UnitedHealthcare Medicaid	$69.25
Rate for Payer: UnitedHealthcare Medicare	$760.00
Rate for Payer: University Health Alliance Commercial	$212.97

XR Arthrogram Injection Ankle Right

Facility

$1,520.00

Service Code	HCPCS 73615 RT
Hospital Charge Code	1169952
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

XR Arthrogram Injection Elbow Left

Facility

$1,520.00

Service Code	HCPCS 73085 LT
Hospital Charge Code	1169956
Hospital Revenue Code	320
Min. Negotiated Rate	$1,292.00
Max. Negotiated Rate	$1,474.40
Rate for Payer: Cash Price	$988.00
Rate for Payer: Health Management Network Commercial	$1,292.00
Rate for Payer: Kaiser Permanente Commercial	$1,368.00
Rate for Payer: MDX Hawaii PPO	$1,474.40

Know your out-of-pocket cost for care.

All Charges