Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Foot Complete 3+ Views Bilateral

Facility

$440.00

Service Code	HCPCS 73630 50
Hospital Charge Code	1170189
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$19.08
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.03
Rate for Payer: Hawaii Western Management Group Commercial	$418.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$19.08
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$62.59

XR Foot Complete 3+ Views Bilateral - Report

Professional

Both

$66.00

Service Code	HCPCS 73630 26,50
Hospital Charge Code	630554
Hospital Revenue Code	972
Min. Negotiated Rate	$22.90
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$22.90
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	$22.90
Rate for Payer: UnitedHealthcare Medicaid	$22.90

XR Foot Complete 3+ Views Left

Facility

$440.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	1170191
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$19.08
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.03
Rate for Payer: Hawaii Western Management Group Commercial	$418.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$19.08
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$62.59

XR Foot Complete 3+ Views Left

Facility

$440.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	1170191
Hospital Revenue Code	320
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

XR Foot Complete 3+ Views Left - Report

Professional

Both

$66.00

Service Code	HCPCS 73630 26,LT
Hospital Charge Code	630550
Hospital Revenue Code	972
Min. Negotiated Rate	$22.90
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$22.90
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	$22.90
Rate for Payer: UnitedHealthcare Medicaid	$22.90

XR Foot Complete 3+ Views Right

Facility

$440.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	1170193
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$19.08
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.03
Rate for Payer: Hawaii Western Management Group Commercial	$418.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$19.08
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$62.59

XR Foot Complete 3+ Views Right

Facility

$440.00

Service Code	HCPCS 73630 RT
Hospital Charge Code	1170193
Hospital Revenue Code	320
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

XR Foot Complete 3+ Views Right - Report

Professional

Both

$66.00

Service Code	HCPCS 73630 26,RT
Hospital Charge Code	630534
Hospital Revenue Code	972
Min. Negotiated Rate	$22.90
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$22.90
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	$22.90
Rate for Payer: UnitedHealthcare Medicaid	$22.90

XR Forearm 2 Views Bilateral

Facility

$440.00

Service Code	HCPCS 73090 50
Hospital Charge Code	1170195
Hospital Revenue Code	320
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

XR Forearm 2 Views Bilateral

Facility

$440.00

Service Code	HCPCS 73090 50
Hospital Charge Code	1170195
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$418.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Forearm 2 Views Bilateral - Report

Professional

Both

$60.00

Service Code	HCPCS 73090 26,50
Hospital Charge Code	630528
Hospital Revenue Code	972
Min. Negotiated Rate	$19.48
Max. Negotiated Rate	$51.00
Rate for Payer: AlohaCare Medicaid	$19.48
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Ohana Health Plan Medicaid	$19.48
Rate for Payer: UnitedHealthcare Medicaid	$19.48

XR Forearm 2 Views Left

Facility

$440.00

Service Code	HCPCS 73090 LT
Hospital Charge Code	1170197
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$418.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Forearm 2 Views Left

Facility

$440.00

Service Code	HCPCS 73090 LT
Hospital Charge Code	1170197
Hospital Revenue Code	320
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

XR Forearm 2 Views Left - Report

Professional

Both

$60.00

Service Code	HCPCS 73090 26,LT
Hospital Charge Code	630524
Hospital Revenue Code	972
Min. Negotiated Rate	$19.48
Max. Negotiated Rate	$51.00
Rate for Payer: AlohaCare Medicaid	$19.48
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Ohana Health Plan Medicaid	$19.48
Rate for Payer: UnitedHealthcare Medicaid	$19.48

XR Forearm 2 Views Right

Facility

$440.00

Service Code	HCPCS 73090 RT
Hospital Charge Code	1170199
Hospital Revenue Code	320
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

XR Forearm 2 Views Right

Facility

$440.00

Service Code	HCPCS 73090 RT
Hospital Charge Code	1170199
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$418.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Forearm 2 Views Right - Report

Professional

Both

$60.00

Service Code	HCPCS 73090 26,RT
Hospital Charge Code	630520
Hospital Revenue Code	972
Min. Negotiated Rate	$19.48
Max. Negotiated Rate	$51.00
Rate for Payer: AlohaCare Medicaid	$19.48
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Ohana Health Plan Medicaid	$19.48
Rate for Payer: UnitedHealthcare Medicaid	$19.48

XR Foreign Body Localization Child 1 Vw

Facility

$461.00

Service Code	HCPCS 76010
Hospital Charge Code	1170207
Hospital Revenue Code	320
Min. Negotiated Rate	$391.85
Max. Negotiated Rate	$447.17
Rate for Payer: Cash Price	$299.65
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: MDX Hawaii PPO	$447.17

XR Foreign Body Localization Child 1 Vw

Facility

$461.00

Service Code	HCPCS 76010
Hospital Charge Code	1170207
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$447.17
Rate for Payer: AlohaCare Medicaid	$230.50
Rate for Payer: AlohaCare Medicare	$230.50
Rate for Payer: Cash Price	$299.65
Rate for Payer: Cash Price	$299.65
Rate for Payer: Devoted Health Medicare	$253.55
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$230.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Humana Medicare	$230.50
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: Kaiser Permanente Medicaid	$235.11
Rate for Payer: Kaiser Permanente Medicare	$230.50
Rate for Payer: MDX Hawaii PPO	$447.17
Rate for Payer: Ohana Health Plan Medicaid	$230.50
Rate for Payer: Ohana Health Plan Medicare	$230.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$230.50
Rate for Payer: University Health Alliance Commercial	$57.68

XR Foreign Body Localization Child 1 Vw - Report

Professional

Both

$70.00

Service Code	HCPCS 76010 26
Hospital Charge Code	630504
Hospital Revenue Code	972
Min. Negotiated Rate	$8.48
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$19.42
Rate for Payer: AlohaCare Medicare	$8.48
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Devoted Health Medicare	$9.33
Rate for Payer: Hawaii Medical Service Association Medicare	$8.48
Rate for Payer: Hawaii Western Management Group Commercial	$32.81
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$9.33
Rate for Payer: Kaiser Permanente Medicaid	$9.33
Rate for Payer: Kaiser Permanente Medicare	$9.33
Rate for Payer: Ohana Health Plan Medicaid	$19.42
Rate for Payer: Ohana Health Plan Medicare	$8.48
Rate for Payer: UnitedHealthcare Medicaid	$19.42
Rate for Payer: UnitedHealthcare Medicare	$8.48

XR Foreign Body Localization Eye

Facility

$394.00

Service Code	HCPCS 70030 50
Hospital Charge Code	1170203
Hospital Revenue Code	320
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$256.10
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18

XR Foreign Body Localization Eye

Facility

$394.00

Service Code	HCPCS 70030 50
Hospital Charge Code	1170203
Hospital Revenue Code	320
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$197.00
Rate for Payer: Cash Price	$256.10
Rate for Payer: Cash Price	$256.10
Rate for Payer: Devoted Health Medicare	$216.70
Rate for Payer: Hawaii Medical Service Association ABD	$13.91
Rate for Payer: Hawaii Medical Service Association Medicare	$197.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.15
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$197.00
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$197.00
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$197.00
Rate for Payer: Ohana Health Plan Medicare	$197.00
Rate for Payer: UnitedHealthcare Medicaid	$13.91
Rate for Payer: UnitedHealthcare Medicare	$197.00
Rate for Payer: University Health Alliance Commercial	$55.37

XR Foreign Body Localization Eye - Report

Professional

Both

$121.00

Service Code	HCPCS 70030 26,50
Hospital Charge Code	630512
Hospital Revenue Code	972
Min. Negotiated Rate	$21.72
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$21.72
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$27.84
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$21.72
Rate for Payer: UnitedHealthcare Medicaid	$21.72

XR Hand 2 Views Bilateral

Facility

$440.00

Service Code	HCPCS 73120 50
Hospital Charge Code	1170213
Hospital Revenue Code	320
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

XR Hand 2 Views Bilateral

Facility

$440.00

Service Code	HCPCS 73120 50
Hospital Charge Code	1170213
Hospital Revenue Code	320
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.55
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.43
Rate for Payer: Hawaii Western Management Group Commercial	$418.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$17.55
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$55.46

Know your out-of-pocket cost for care.

All Charges