Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Clavicle Left - Report

Professional

Both

$70.00

Service Code	HCPCS 73000 26,LT
Hospital Charge Code	629753
Hospital Revenue Code	972
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$21.78

XR Clavicle Right

Facility

$430.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	1170077
Hospital Revenue Code	320
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$279.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: MDX Hawaii PPO	$417.10

XR Clavicle Right

Facility

$430.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	1170077
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$417.10
Rate for Payer: AlohaCare Medicaid	$215.00
Rate for Payer: AlohaCare Medicare	$215.00
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$236.50
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$215.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$408.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Humana Medicare	$215.00
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: Kaiser Permanente Medicaid	$219.30
Rate for Payer: Kaiser Permanente Medicare	$215.00
Rate for Payer: MDX Hawaii PPO	$417.10
Rate for Payer: Ohana Health Plan Medicaid	$215.00
Rate for Payer: Ohana Health Plan Medicare	$215.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$215.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Clavicle Right - Report

Professional

Both

$70.00

Service Code	HCPCS 73000 26,RT
Hospital Charge Code	629755
Hospital Revenue Code	972
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$21.78

XR Cystogram

Facility

$1,114.00

Service Code	HCPCS 74430
Hospital Charge Code	8221475
Hospital Revenue Code	320
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$1,080.58
Rate for Payer: AlohaCare Medicaid	$557.00
Rate for Payer: AlohaCare Medicare	$557.00
Rate for Payer: Cash Price	$724.10
Rate for Payer: Cash Price	$724.10
Rate for Payer: Devoted Health Medicare	$612.70
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$557.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$946.90
Rate for Payer: Humana Medicare	$557.00
Rate for Payer: Kaiser Permanente Commercial	$1,002.60
Rate for Payer: Kaiser Permanente Medicaid	$568.14
Rate for Payer: Kaiser Permanente Medicare	$557.00
Rate for Payer: MDX Hawaii PPO	$1,080.58
Rate for Payer: Ohana Health Plan Medicaid	$557.00
Rate for Payer: Ohana Health Plan Medicare	$557.00
Rate for Payer: UnitedHealthcare Medicaid	$34.94
Rate for Payer: UnitedHealthcare Medicare	$557.00
Rate for Payer: University Health Alliance Commercial	$148.81

XR Cystogram

Facility

$1,114.00

Service Code	HCPCS 74430
Hospital Charge Code	8221475
Hospital Revenue Code	320
Min. Negotiated Rate	$946.90
Max. Negotiated Rate	$1,080.58
Rate for Payer: Cash Price	$724.10
Rate for Payer: Health Management Network Commercial	$946.90
Rate for Payer: Kaiser Permanente Commercial	$1,002.60
Rate for Payer: MDX Hawaii PPO	$1,080.58

XR Cystogram - Report

Professional

Both

$486.00

Service Code	HCPCS 74430 26
Hospital Charge Code	2425448
Hospital Revenue Code	972
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$413.10
Rate for Payer: AlohaCare Medicaid	$27.15
Rate for Payer: AlohaCare Medicare	$15.30
Rate for Payer: Cash Price	$315.90
Rate for Payer: Cash Price	$315.90
Rate for Payer: Devoted Health Medicare	$16.83
Rate for Payer: Hawaii Medical Service Association Medicare	$15.30
Rate for Payer: Hawaii Western Management Group Commercial	$63.84
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Kaiser Permanente Commercial	$16.83
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$16.83
Rate for Payer: Ohana Health Plan Medicaid	$27.15
Rate for Payer: Ohana Health Plan Medicare	$15.30
Rate for Payer: UnitedHealthcare Medicaid	$27.15
Rate for Payer: UnitedHealthcare Medicare	$15.30

XR Cystogram/Urethrogram Injection

Facility

$730.00

Service Code	HCPCS 51610
Hospital Charge Code	9803541
Hospital Revenue Code	320
Min. Negotiated Rate	$620.50
Max. Negotiated Rate	$708.10
Rate for Payer: Cash Price	$474.50
Rate for Payer: Health Management Network Commercial	$620.50
Rate for Payer: Kaiser Permanente Commercial	$657.00
Rate for Payer: MDX Hawaii PPO	$708.10

XR Cystogram/Urethrogram Injection

Facility

$730.00

Service Code	HCPCS 51610
Hospital Charge Code	9803541
Hospital Revenue Code	320
Min. Negotiated Rate	$40.43
Max. Negotiated Rate	$708.10
Rate for Payer: AlohaCare Medicaid	$365.00
Rate for Payer: AlohaCare Medicare	$365.00
Rate for Payer: Cash Price	$474.50
Rate for Payer: Cash Price	$474.50
Rate for Payer: Devoted Health Medicare	$401.50
Rate for Payer: Hawaii Medical Service Association Medicare	$365.00
Rate for Payer: Hawaii Western Management Group Commercial	$693.50
Rate for Payer: Health Management Network Commercial	$620.50
Rate for Payer: Humana Medicare	$365.00
Rate for Payer: Kaiser Permanente Commercial	$657.00
Rate for Payer: Kaiser Permanente Medicaid	$372.30
Rate for Payer: Kaiser Permanente Medicare	$365.00
Rate for Payer: MDX Hawaii PPO	$708.10
Rate for Payer: Ohana Health Plan Medicaid	$365.00
Rate for Payer: Ohana Health Plan Medicare	$365.00
Rate for Payer: UnitedHealthcare Medicaid	$40.43
Rate for Payer: UnitedHealthcare Medicare	$365.00
Rate for Payer: University Health Alliance Commercial	$532.10

XR Cystogram/Urethrogram Injection - Report

Professional

Both

$338.00

Service Code	HCPCS 51610
Hospital Charge Code	9803543
Hospital Revenue Code	975
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$287.30
Rate for Payer: AlohaCare Medicaid	$65.50
Rate for Payer: AlohaCare Medicare	$58.80
Rate for Payer: Cash Price	$219.70
Rate for Payer: Cash Price	$219.70
Rate for Payer: Devoted Health Medicare	$64.68
Rate for Payer: Hawaii Medical Service Association ABD	$65.50
Rate for Payer: Hawaii Medical Service Association Commercial	$107.97
Rate for Payer: Hawaii Medical Service Association Medicare	$58.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$65.50
Rate for Payer: Hawaii Western Management Group Commercial	$71.50
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: Kaiser Permanente Commercial	$64.68
Rate for Payer: Kaiser Permanente Medicaid	$64.68
Rate for Payer: Kaiser Permanente Medicare	$64.68
Rate for Payer: Ohana Health Plan Medicaid	$65.50
Rate for Payer: Ohana Health Plan Medicare	$58.80
Rate for Payer: UnitedHealthcare Medicaid	$65.50
Rate for Payer: UnitedHealthcare Medicare	$58.80
Rate for Payer: University Health Alliance Commercial	$85.04

XR Drainage Perc Cath Placement

Facility

$1,234.00

Service Code	HCPCS 75989
Hospital Charge Code	8207975
Hospital Revenue Code	350
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

XR Drainage Perc Cath Placement

Facility

$1,234.00

Service Code	HCPCS 75989
Hospital Charge Code	8207975
Hospital Revenue Code	350
Min. Negotiated Rate	$103.94
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	$103.94
Rate for Payer: Hawaii Medical Service Association Medicare	$617.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$112.58
Rate for Payer: Hawaii Western Management Group Commercial	$1,172.30
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	$103.94
Rate for Payer: UnitedHealthcare Medicare	$617.00
Rate for Payer: University Health Alliance Commercial	$317.64

XR Drainage Perc Cath Placement - Report

Professional

Both

$166.00

Service Code	HCPCS 75989 26
Hospital Charge Code	8207977
Hospital Revenue Code	972
Min. Negotiated Rate	$55.10
Max. Negotiated Rate	$202.69
Rate for Payer: AlohaCare Medicaid	$72.05
Rate for Payer: AlohaCare Medicare	$55.10
Rate for Payer: Cash Price	$107.90
Rate for Payer: Cash Price	$107.90
Rate for Payer: Devoted Health Medicare	$60.61
Rate for Payer: Hawaii Medical Service Association Medicare	$55.10
Rate for Payer: Hawaii Western Management Group Commercial	$202.69
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$60.61
Rate for Payer: Kaiser Permanente Medicaid	$60.61
Rate for Payer: Kaiser Permanente Medicare	$60.61
Rate for Payer: Ohana Health Plan Medicaid	$72.05
Rate for Payer: Ohana Health Plan Medicare	$55.10
Rate for Payer: UnitedHealthcare Medicaid	$72.05
Rate for Payer: UnitedHealthcare Medicare	$55.10

XR Elbow 2 Views Bilateral

Facility

$327.00

Service Code	HCPCS 73070 50
Hospital Charge Code	1170119
Hospital Revenue Code	320
Min. Negotiated Rate	$277.95
Max. Negotiated Rate	$317.19
Rate for Payer: Cash Price	$212.55
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: MDX Hawaii PPO	$317.19

XR Elbow 2 Views Bilateral

Facility

$327.00

Service Code	HCPCS 73070 50
Hospital Charge Code	1170119
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$317.19
Rate for Payer: AlohaCare Medicaid	$163.50
Rate for Payer: AlohaCare Medicare	$163.50
Rate for Payer: Cash Price	$212.55
Rate for Payer: Cash Price	$212.55
Rate for Payer: Devoted Health Medicare	$179.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$163.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$310.65
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Humana Medicare	$163.50
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: Kaiser Permanente Medicaid	$166.77
Rate for Payer: Kaiser Permanente Medicare	$163.50
Rate for Payer: MDX Hawaii PPO	$317.19
Rate for Payer: Ohana Health Plan Medicaid	$163.50
Rate for Payer: Ohana Health Plan Medicare	$163.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$163.50
Rate for Payer: University Health Alliance Commercial	$55.57

XR Elbow 2 Views Bilateral - Report

Professional

Both

$121.00

Service Code	HCPCS 73070 26,50
Hospital Charge Code	630692
Hospital Revenue Code	972
Min. Negotiated Rate	$19.48
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$19.48
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$31.36
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$19.48
Rate for Payer: UnitedHealthcare Medicaid	$19.48

XR Elbow 2 Views Left

Facility

$327.00

Service Code	HCPCS 73070 LT
Hospital Charge Code	1170121
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$317.19
Rate for Payer: AlohaCare Medicaid	$163.50
Rate for Payer: AlohaCare Medicare	$163.50
Rate for Payer: Cash Price	$212.55
Rate for Payer: Cash Price	$212.55
Rate for Payer: Devoted Health Medicare	$179.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$163.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$310.65
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Humana Medicare	$163.50
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: Kaiser Permanente Medicaid	$166.77
Rate for Payer: Kaiser Permanente Medicare	$163.50
Rate for Payer: MDX Hawaii PPO	$317.19
Rate for Payer: Ohana Health Plan Medicaid	$163.50
Rate for Payer: Ohana Health Plan Medicare	$163.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$163.50
Rate for Payer: University Health Alliance Commercial	$55.57

XR Elbow 2 Views Left

Facility

$327.00

Service Code	HCPCS 73070 LT
Hospital Charge Code	1170121
Hospital Revenue Code	320
Min. Negotiated Rate	$277.95
Max. Negotiated Rate	$317.19
Rate for Payer: Cash Price	$212.55
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: MDX Hawaii PPO	$317.19

XR Elbow 2 Views Left - Report

Professional

Both

$121.00

Service Code	HCPCS 73070 26,LT
Hospital Charge Code	630690
Hospital Revenue Code	972
Min. Negotiated Rate	$19.48
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$19.48
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$31.36
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$19.48
Rate for Payer: UnitedHealthcare Medicaid	$19.48

XR Elbow 2 Views Right

Facility

$327.00

Service Code	HCPCS 73070 RT
Hospital Charge Code	1170123
Hospital Revenue Code	320
Min. Negotiated Rate	$277.95
Max. Negotiated Rate	$317.19
Rate for Payer: Cash Price	$212.55
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: MDX Hawaii PPO	$317.19

XR Elbow 2 Views Right

Facility

$327.00

Service Code	HCPCS 73070 RT
Hospital Charge Code	1170123
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$317.19
Rate for Payer: AlohaCare Medicaid	$163.50
Rate for Payer: AlohaCare Medicare	$163.50
Rate for Payer: Cash Price	$212.55
Rate for Payer: Cash Price	$212.55
Rate for Payer: Devoted Health Medicare	$179.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$163.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$310.65
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Humana Medicare	$163.50
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: Kaiser Permanente Medicaid	$166.77
Rate for Payer: Kaiser Permanente Medicare	$163.50
Rate for Payer: MDX Hawaii PPO	$317.19
Rate for Payer: Ohana Health Plan Medicaid	$163.50
Rate for Payer: Ohana Health Plan Medicare	$163.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$163.50
Rate for Payer: University Health Alliance Commercial	$55.57

XR Elbow 2 Views Right - Report

Professional

Both

$121.00

Service Code	HCPCS 73070 26,RT
Hospital Charge Code	630688
Hospital Revenue Code	972
Min. Negotiated Rate	$19.48
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$19.48
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$31.36
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$19.48
Rate for Payer: UnitedHealthcare Medicaid	$19.48

XR Elbow Complete 3+ Views Bilateral

Facility

$525.00

Service Code	HCPCS 73080 50
Hospital Charge Code	1170125
Hospital Revenue Code	320
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: MDX Hawaii PPO	$509.25

XR Elbow Complete 3+ Views Bilateral

Facility

$525.00

Service Code	HCPCS 73080 50
Hospital Charge Code	1170125
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$509.25
Rate for Payer: AlohaCare Medicaid	$262.50
Rate for Payer: AlohaCare Medicare	$262.50
Rate for Payer: Cash Price	$341.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Devoted Health Medicare	$288.75
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
Rate for Payer: Hawaii Western Management Group Commercial	$498.75
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Humana Medicare	$262.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: Kaiser Permanente Medicare	$262.50
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: Ohana Health Plan Medicaid	$262.50
Rate for Payer: Ohana Health Plan Medicare	$262.50
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$68.41

XR Elbow Complete 3+ Views Bilateral - Report

Professional

Both

$121.00

Service Code	HCPCS 73080 26,50
Hospital Charge Code	630686
Hospital Revenue Code	972
Min. Negotiated Rate	$21.98
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$21.98
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$34.64
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$21.98
Rate for Payer: UnitedHealthcare Medicaid	$21.98

Know your out-of-pocket cost for care.

All Charges