Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Hand 2 Views Bilateral - Report

Professional

Both

$86.00

Service Code	HCPCS 73120 26,50
Hospital Charge Code	630500
Hospital Revenue Code	972
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$21.09
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Ohana Health Plan Medicaid	$21.09
Rate for Payer: UnitedHealthcare Medicaid	$21.09

XR Hand 2 Views Left

Facility

$440.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	1170215
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

XR Hand 2 Views Left

Facility

$440.00

Service Code	HCPCS 73120 LT
Hospital Charge Code	1170215
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 Left - Report

Professional

Both

$60.00

Service Code	HCPCS 73120 26,LT
Hospital Charge Code	630494
Hospital Revenue Code	972
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$51.00
Rate for Payer: AlohaCare Medicaid	$21.09
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Ohana Health Plan Medicaid	$21.09
Rate for Payer: UnitedHealthcare Medicaid	$21.09

XR Hand 2 Views Right

Facility

$440.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	1170217
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

XR Hand 2 Views Right

Facility

$440.00

Service Code	HCPCS 73120 RT
Hospital Charge Code	1170217
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 Right - Report

Professional

Both

$60.00

Service Code	HCPCS 73120 26,RT
Hospital Charge Code	630490
Hospital Revenue Code	972
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$51.00
Rate for Payer: AlohaCare Medicaid	$21.09
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Ohana Health Plan Medicaid	$21.09
Rate for Payer: UnitedHealthcare Medicaid	$21.09

XR Hand Complete 3+ Views Bilateral

Facility

$525.00

Service Code	HCPCS 73130 50
Hospital Charge Code	1170219
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 Hand Complete 3+ Views Bilateral

Facility

$525.00

Service Code	HCPCS 73130 50
Hospital Charge Code	1170219
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
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	$19.08
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.03
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	$19.08
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$62.59

XR Hand Complete 3+ Views Bilateral - Report

Professional

Both

$66.00

Service Code	HCPCS 73130 26,50
Hospital Charge Code	630484
Hospital Revenue Code	972
Min. Negotiated Rate	$24.96
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$24.96
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	$24.96
Rate for Payer: UnitedHealthcare Medicaid	$24.96

XR Hand Complete 3+ Views Left

Facility

$525.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	1170221
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 Hand Complete 3+ Views Left

Facility

$525.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	1170221
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
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	$19.08
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.03
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	$19.08
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$62.59

XR Hand Complete 3+ Views Left - Report

Professional

Both

$66.00

Service Code	HCPCS 73130 26,LT
Hospital Charge Code	630480
Hospital Revenue Code	972
Min. Negotiated Rate	$24.96
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$24.96
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	$24.96
Rate for Payer: UnitedHealthcare Medicaid	$24.96

XR Hand Complete 3+ Views Right

Facility

$525.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	1170223
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 Hand Complete 3+ Views Right

Facility

$525.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	1170223
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
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	$19.08
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.03
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	$19.08
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$62.59

XR Hand Complete 3+ Views Right - Report

Professional

Both

$66.00

Service Code	HCPCS 73130 26,RT
Hospital Charge Code	630475
Hospital Revenue Code	972
Min. Negotiated Rate	$24.96
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$24.96
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	$24.96
Rate for Payer: UnitedHealthcare Medicaid	$24.96

XR Hip 1 View Left

Facility

$406.00

Service Code	HCPCS 73501 LT
Hospital Charge Code	1170225
Hospital Revenue Code	320
Min. Negotiated Rate	$14.12
Max. Negotiated Rate	$393.82
Rate for Payer: AlohaCare Medicaid	$203.00
Rate for Payer: AlohaCare Medicare	$203.00
Rate for Payer: Cash Price	$263.90
Rate for Payer: Cash Price	$263.90
Rate for Payer: Devoted Health Medicare	$223.30
Rate for Payer: Hawaii Medical Service Association ABD	$14.12
Rate for Payer: Hawaii Medical Service Association Medicare	$203.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.28
Rate for Payer: Hawaii Western Management Group Commercial	$385.70
Rate for Payer: Health Management Network Commercial	$345.10
Rate for Payer: Humana Medicare	$203.00
Rate for Payer: Kaiser Permanente Commercial	$365.40
Rate for Payer: Kaiser Permanente Medicaid	$207.06
Rate for Payer: Kaiser Permanente Medicare	$203.00
Rate for Payer: MDX Hawaii PPO	$393.82
Rate for Payer: Ohana Health Plan Medicaid	$203.00
Rate for Payer: Ohana Health Plan Medicare	$203.00
Rate for Payer: UnitedHealthcare Medicaid	$21.95
Rate for Payer: UnitedHealthcare Medicare	$203.00
Rate for Payer: University Health Alliance Commercial	$61.27

XR Hip 1 View Left

Facility

$406.00

Service Code	HCPCS 73501 LT
Hospital Charge Code	1170225
Hospital Revenue Code	320
Min. Negotiated Rate	$345.10
Max. Negotiated Rate	$393.82
Rate for Payer: Cash Price	$263.90
Rate for Payer: Health Management Network Commercial	$345.10
Rate for Payer: Kaiser Permanente Commercial	$365.40
Rate for Payer: MDX Hawaii PPO	$393.82

XR Hip 1 View Left - Report

Professional

Both

$90.00

Service Code	HCPCS 73501 26,LT
Hospital Charge Code	630470
Hospital Revenue Code	972
Min. Negotiated Rate	$21.95
Max. Negotiated Rate	$76.50
Rate for Payer: AlohaCare Medicaid	$21.95
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Hawaii Western Management Group Commercial	$33.12
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Ohana Health Plan Medicaid	$21.95
Rate for Payer: UnitedHealthcare Medicaid	$21.95

XR Hip 1 View Right

Facility

$406.00

Service Code	HCPCS 73501 RT
Hospital Charge Code	1170227
Hospital Revenue Code	320
Min. Negotiated Rate	$345.10
Max. Negotiated Rate	$393.82
Rate for Payer: Cash Price	$263.90
Rate for Payer: Health Management Network Commercial	$345.10
Rate for Payer: Kaiser Permanente Commercial	$365.40
Rate for Payer: MDX Hawaii PPO	$393.82

XR Hip 1 View Right

Facility

$406.00

Service Code	HCPCS 73501 RT
Hospital Charge Code	1170227
Hospital Revenue Code	320
Min. Negotiated Rate	$14.12
Max. Negotiated Rate	$393.82
Rate for Payer: AlohaCare Medicaid	$203.00
Rate for Payer: AlohaCare Medicare	$203.00
Rate for Payer: Cash Price	$263.90
Rate for Payer: Cash Price	$263.90
Rate for Payer: Devoted Health Medicare	$223.30
Rate for Payer: Hawaii Medical Service Association ABD	$14.12
Rate for Payer: Hawaii Medical Service Association Medicare	$203.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.28
Rate for Payer: Hawaii Western Management Group Commercial	$385.70
Rate for Payer: Health Management Network Commercial	$345.10
Rate for Payer: Humana Medicare	$203.00
Rate for Payer: Kaiser Permanente Commercial	$365.40
Rate for Payer: Kaiser Permanente Medicaid	$207.06
Rate for Payer: Kaiser Permanente Medicare	$203.00
Rate for Payer: MDX Hawaii PPO	$393.82
Rate for Payer: Ohana Health Plan Medicaid	$203.00
Rate for Payer: Ohana Health Plan Medicare	$203.00
Rate for Payer: UnitedHealthcare Medicaid	$21.95
Rate for Payer: UnitedHealthcare Medicare	$203.00
Rate for Payer: University Health Alliance Commercial	$61.27

XR Hip 1 View Right - Report

Professional

Both

$70.00

Service Code	HCPCS 73501 26,RT
Hospital Charge Code	630466
Hospital Revenue Code	972
Min. Negotiated Rate	$21.95
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$21.95
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$33.12
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$21.95
Rate for Payer: UnitedHealthcare Medicaid	$21.95

XR Hip 2-3 Views Left

Facility

$406.00

Service Code	HCPCS 73502 LT
Hospital Charge Code	7520582
Hospital Revenue Code	320
Min. Negotiated Rate	$20.87
Max. Negotiated Rate	$393.82
Rate for Payer: AlohaCare Medicaid	$203.00
Rate for Payer: AlohaCare Medicare	$203.00
Rate for Payer: Cash Price	$263.90
Rate for Payer: Cash Price	$263.90
Rate for Payer: Devoted Health Medicare	$223.30
Rate for Payer: Hawaii Medical Service Association ABD	$20.87
Rate for Payer: Hawaii Medical Service Association Medicare	$203.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.52
Rate for Payer: Hawaii Western Management Group Commercial	$385.70
Rate for Payer: Health Management Network Commercial	$345.10
Rate for Payer: Humana Medicare	$203.00
Rate for Payer: Kaiser Permanente Commercial	$365.40
Rate for Payer: Kaiser Permanente Medicaid	$207.06
Rate for Payer: Kaiser Permanente Medicare	$203.00
Rate for Payer: MDX Hawaii PPO	$393.82
Rate for Payer: Ohana Health Plan Medicaid	$203.00
Rate for Payer: Ohana Health Plan Medicare	$203.00
Rate for Payer: UnitedHealthcare Medicaid	$31.93
Rate for Payer: UnitedHealthcare Medicare	$203.00
Rate for Payer: University Health Alliance Commercial	$86.21

XR Hip 2-3 Views Left

Facility

$406.00

Service Code	HCPCS 73502 LT
Hospital Charge Code	7520582
Hospital Revenue Code	320
Min. Negotiated Rate	$345.10
Max. Negotiated Rate	$393.82
Rate for Payer: Cash Price	$263.90
Rate for Payer: Health Management Network Commercial	$345.10
Rate for Payer: Kaiser Permanente Commercial	$365.40
Rate for Payer: MDX Hawaii PPO	$393.82

XR Hip 2-3 Views Left - Report

Professional

Both

$121.00

Service Code	HCPCS 73502 26,LT
Hospital Charge Code	7520584
Hospital Revenue Code	972
Min. Negotiated Rate	$31.93
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$31.93
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$46.62
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$31.93
Rate for Payer: UnitedHealthcare Medicaid	$31.93

Know your out-of-pocket cost for care.

All Charges