Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Hip 2-3 Views Right

Facility

$406.00

Service Code	HCPCS 73502 RT
Hospital Charge Code	7520585
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 Right

Facility

$406.00

Service Code	HCPCS 73502 RT
Hospital Charge Code	7520585
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 Right - Report

Professional

Both

$121.00

Service Code	HCPCS 73502 26,RT
Hospital Charge Code	7520587
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

XR Hip 4+ Views Left

Facility

$609.00

Service Code	HCPCS 73503 LT
Hospital Charge Code	7520594
Hospital Revenue Code	320
Min. Negotiated Rate	$517.65
Max. Negotiated Rate	$590.73
Rate for Payer: Cash Price	$395.85
Rate for Payer: Health Management Network Commercial	$517.65
Rate for Payer: Kaiser Permanente Commercial	$548.10
Rate for Payer: MDX Hawaii PPO	$590.73

XR Hip 4+ Views Left

Facility

$609.00

Service Code	HCPCS 73503 LT
Hospital Charge Code	7520594
Hospital Revenue Code	320
Min. Negotiated Rate	$25.86
Max. Negotiated Rate	$590.73
Rate for Payer: AlohaCare Medicaid	$304.50
Rate for Payer: AlohaCare Medicare	$304.50
Rate for Payer: Cash Price	$395.85
Rate for Payer: Cash Price	$395.85
Rate for Payer: Devoted Health Medicare	$334.95
Rate for Payer: Hawaii Medical Service Association ABD	$25.86
Rate for Payer: Hawaii Medical Service Association Medicare	$304.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$35.34
Rate for Payer: Hawaii Western Management Group Commercial	$578.55
Rate for Payer: Health Management Network Commercial	$517.65
Rate for Payer: Humana Medicare	$304.50
Rate for Payer: Kaiser Permanente Commercial	$548.10
Rate for Payer: Kaiser Permanente Medicaid	$310.59
Rate for Payer: Kaiser Permanente Medicare	$304.50
Rate for Payer: MDX Hawaii PPO	$590.73
Rate for Payer: Ohana Health Plan Medicaid	$304.50
Rate for Payer: Ohana Health Plan Medicare	$304.50
Rate for Payer: UnitedHealthcare Medicaid	$40.27
Rate for Payer: UnitedHealthcare Medicare	$304.50
Rate for Payer: University Health Alliance Commercial	$123.25

XR Hip 4+ Views Left - Report

Professional

Both

$145.00

Service Code	HCPCS 73503 26,LT
Hospital Charge Code	7520596
Hospital Revenue Code	972
Min. Negotiated Rate	$40.27
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$40.27
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$58.20
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$40.27
Rate for Payer: UnitedHealthcare Medicaid	$40.27

XR Hip 4+ Views Right

Facility

$609.00

Service Code	HCPCS 73503 RT
Hospital Charge Code	7520597
Hospital Revenue Code	320
Min. Negotiated Rate	$517.65
Max. Negotiated Rate	$590.73
Rate for Payer: Cash Price	$395.85
Rate for Payer: Health Management Network Commercial	$517.65
Rate for Payer: Kaiser Permanente Commercial	$548.10
Rate for Payer: MDX Hawaii PPO	$590.73

XR Hip 4+ Views Right

Facility

$609.00

Service Code	HCPCS 73503 RT
Hospital Charge Code	7520597
Hospital Revenue Code	320
Min. Negotiated Rate	$25.86
Max. Negotiated Rate	$590.73
Rate for Payer: AlohaCare Medicaid	$304.50
Rate for Payer: AlohaCare Medicare	$304.50
Rate for Payer: Cash Price	$395.85
Rate for Payer: Cash Price	$395.85
Rate for Payer: Devoted Health Medicare	$334.95
Rate for Payer: Hawaii Medical Service Association ABD	$25.86
Rate for Payer: Hawaii Medical Service Association Medicare	$304.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$35.34
Rate for Payer: Hawaii Western Management Group Commercial	$578.55
Rate for Payer: Health Management Network Commercial	$517.65
Rate for Payer: Humana Medicare	$304.50
Rate for Payer: Kaiser Permanente Commercial	$548.10
Rate for Payer: Kaiser Permanente Medicaid	$310.59
Rate for Payer: Kaiser Permanente Medicare	$304.50
Rate for Payer: MDX Hawaii PPO	$590.73
Rate for Payer: Ohana Health Plan Medicaid	$304.50
Rate for Payer: Ohana Health Plan Medicare	$304.50
Rate for Payer: UnitedHealthcare Medicaid	$40.27
Rate for Payer: UnitedHealthcare Medicare	$304.50
Rate for Payer: University Health Alliance Commercial	$123.25

XR Hip 4+ Views Right - Report

Professional

Both

$145.00

Service Code	HCPCS 73503 26,RT
Hospital Charge Code	7520599
Hospital Revenue Code	972
Min. Negotiated Rate	$40.27
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$40.27
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$58.20
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$40.27
Rate for Payer: UnitedHealthcare Medicaid	$40.27

XR Hips 2 Views Bilat

Facility

$669.00

Service Code	HCPCS 73521
Hospital Charge Code	7520606
Hospital Revenue Code	320
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$648.93
Rate for Payer: AlohaCare Medicaid	$334.50
Rate for Payer: AlohaCare Medicare	$334.50
Rate for Payer: Cash Price	$434.85
Rate for Payer: Cash Price	$434.85
Rate for Payer: Devoted Health Medicare	$367.95
Rate for Payer: Hawaii Medical Service Association ABD	$19.61
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$334.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.81
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$568.65
Rate for Payer: Humana Medicare	$334.50
Rate for Payer: Kaiser Permanente Commercial	$602.10
Rate for Payer: Kaiser Permanente Medicaid	$341.19
Rate for Payer: Kaiser Permanente Medicare	$334.50
Rate for Payer: MDX Hawaii PPO	$648.93
Rate for Payer: Ohana Health Plan Medicaid	$334.50
Rate for Payer: Ohana Health Plan Medicare	$334.50
Rate for Payer: UnitedHealthcare Medicaid	$27.57
Rate for Payer: UnitedHealthcare Medicare	$334.50
Rate for Payer: University Health Alliance Commercial	$82.40

XR Hips 2 Views Bilat

Facility

$669.00

Service Code	HCPCS 73521
Hospital Charge Code	7520606
Hospital Revenue Code	320
Min. Negotiated Rate	$568.65
Max. Negotiated Rate	$648.93
Rate for Payer: Cash Price	$434.85
Rate for Payer: Health Management Network Commercial	$568.65
Rate for Payer: Kaiser Permanente Commercial	$602.10
Rate for Payer: MDX Hawaii PPO	$648.93

XR Hips 2 Views Bilat - Report

Professional

Both

$145.00

Service Code	HCPCS 73521 26
Hospital Charge Code	7520608
Hospital Revenue Code	972
Min. Negotiated Rate	$11.01
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$27.57
Rate for Payer: AlohaCare Medicare	$11.01
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$12.11
Rate for Payer: Hawaii Medical Service Association Medicare	$11.01
Rate for Payer: Hawaii Western Management Group Commercial	$44.55
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$12.11
Rate for Payer: Kaiser Permanente Medicaid	$12.11
Rate for Payer: Kaiser Permanente Medicare	$12.11
Rate for Payer: Ohana Health Plan Medicaid	$27.57
Rate for Payer: Ohana Health Plan Medicare	$11.01
Rate for Payer: UnitedHealthcare Medicaid	$27.57
Rate for Payer: UnitedHealthcare Medicare	$11.01

XR Hips 3-4 Views Bilat

Facility

$669.00

Service Code	HCPCS 73522
Hospital Charge Code	7520612
Hospital Revenue Code	320
Min. Negotiated Rate	$23.36
Max. Negotiated Rate	$648.93
Rate for Payer: AlohaCare Medicaid	$334.50
Rate for Payer: AlohaCare Medicare	$334.50
Rate for Payer: Cash Price	$434.85
Rate for Payer: Cash Price	$434.85
Rate for Payer: Devoted Health Medicare	$367.95
Rate for Payer: Hawaii Medical Service Association ABD	$23.36
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$334.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31.91
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$568.65
Rate for Payer: Humana Medicare	$334.50
Rate for Payer: Kaiser Permanente Commercial	$602.10
Rate for Payer: Kaiser Permanente Medicaid	$341.19
Rate for Payer: Kaiser Permanente Medicare	$334.50
Rate for Payer: MDX Hawaii PPO	$648.93
Rate for Payer: Ohana Health Plan Medicaid	$334.50
Rate for Payer: Ohana Health Plan Medicare	$334.50
Rate for Payer: UnitedHealthcare Medicaid	$36.08
Rate for Payer: UnitedHealthcare Medicare	$334.50
Rate for Payer: University Health Alliance Commercial	$101.31

XR Hips 3-4 Views Bilat

Facility

$669.00

Service Code	HCPCS 73522
Hospital Charge Code	7520612
Hospital Revenue Code	320
Min. Negotiated Rate	$568.65
Max. Negotiated Rate	$648.93
Rate for Payer: Cash Price	$434.85
Rate for Payer: Health Management Network Commercial	$568.65
Rate for Payer: Kaiser Permanente Commercial	$602.10
Rate for Payer: MDX Hawaii PPO	$648.93

XR Hips 3-4 Views Bilat - Report

Professional

Both

$145.00

Service Code	HCPCS 73522 26
Hospital Charge Code	7520614
Hospital Revenue Code	972
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$36.08
Rate for Payer: AlohaCare Medicare	$14.30
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$15.73
Rate for Payer: Hawaii Medical Service Association Medicare	$14.30
Rate for Payer: Hawaii Western Management Group Commercial	$54.76
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$15.73
Rate for Payer: Kaiser Permanente Medicaid	$15.73
Rate for Payer: Kaiser Permanente Medicare	$15.73
Rate for Payer: Ohana Health Plan Medicaid	$36.08
Rate for Payer: Ohana Health Plan Medicare	$14.30
Rate for Payer: UnitedHealthcare Medicaid	$36.08
Rate for Payer: UnitedHealthcare Medicare	$14.30

XR Hips 5+ Views Bilat

Facility

$773.00

Service Code	HCPCS 73523
Hospital Charge Code	7520618
Hospital Revenue Code	320
Min. Negotiated Rate	$657.05
Max. Negotiated Rate	$749.81
Rate for Payer: Cash Price	$502.45
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: Kaiser Permanente Commercial	$695.70
Rate for Payer: MDX Hawaii PPO	$749.81

XR Hips 5+ Views Bilat

Facility

$773.00

Service Code	HCPCS 73523
Hospital Charge Code	7520618
Hospital Revenue Code	320
Min. Negotiated Rate	$28.11
Max. Negotiated Rate	$749.81
Rate for Payer: AlohaCare Medicaid	$386.50
Rate for Payer: AlohaCare Medicare	$386.50
Rate for Payer: Cash Price	$502.45
Rate for Payer: Cash Price	$502.45
Rate for Payer: Devoted Health Medicare	$425.15
Rate for Payer: Hawaii Medical Service Association ABD	$28.11
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$386.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.40
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: Humana Medicare	$386.50
Rate for Payer: Kaiser Permanente Commercial	$695.70
Rate for Payer: Kaiser Permanente Medicaid	$394.23
Rate for Payer: Kaiser Permanente Medicare	$386.50
Rate for Payer: MDX Hawaii PPO	$749.81
Rate for Payer: Ohana Health Plan Medicaid	$386.50
Rate for Payer: Ohana Health Plan Medicare	$386.50
Rate for Payer: UnitedHealthcare Medicaid	$41.41
Rate for Payer: UnitedHealthcare Medicare	$386.50
Rate for Payer: University Health Alliance Commercial	$118.03

XR Hips 5+ Views Bilat - Report

Professional

Both

$145.00

Service Code	HCPCS 73523 26
Hospital Charge Code	7520620
Hospital Revenue Code	972
Min. Negotiated Rate	$14.96
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$41.41
Rate for Payer: AlohaCare Medicare	$14.96
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$16.46
Rate for Payer: Hawaii Medical Service Association Medicare	$14.96
Rate for Payer: Hawaii Western Management Group Commercial	$63.80
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$16.46
Rate for Payer: Kaiser Permanente Medicaid	$16.46
Rate for Payer: Kaiser Permanente Medicare	$16.46
Rate for Payer: Ohana Health Plan Medicaid	$41.41
Rate for Payer: Ohana Health Plan Medicare	$14.96
Rate for Payer: UnitedHealthcare Medicaid	$41.41
Rate for Payer: UnitedHealthcare Medicare	$14.96

XR Humerus Bilat

Facility

$440.00

Service Code	HCPCS 73060 50
Hospital Charge Code	8211785
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
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	$18.84
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
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	$18.84
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$61.20

XR Humerus Bilat

Facility

$440.00

Service Code	HCPCS 73060 50
Hospital Charge Code	8211785
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 Humerus Bilat - Report

Professional

Both

$121.00

Service Code	HCPCS 73060 26,50
Hospital Charge Code	8211787
Hospital Revenue Code	972
Min. Negotiated Rate	$21.32
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$21.32
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	$21.32
Rate for Payer: UnitedHealthcare Medicaid	$21.32

XR Humerus Left

Facility

$440.00

Service Code	HCPCS 73060 LT
Hospital Charge Code	1170245
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
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	$18.84
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
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	$18.84
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$61.20

XR Humerus Left

Facility

$440.00

Service Code	HCPCS 73060 LT
Hospital Charge Code	1170245
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 Humerus Left - Report

Professional

Both

$66.00

Service Code	HCPCS 73060 26,LT
Hospital Charge Code	630430
Hospital Revenue Code	972
Min. Negotiated Rate	$21.32
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$21.32
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$34.64
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Ohana Health Plan Medicaid	$21.32
Rate for Payer: UnitedHealthcare Medicaid	$21.32

XR Humerus Right

Facility

$440.00

Service Code	HCPCS 73060 RT
Hospital Charge Code	1170247
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

Know your out-of-pocket cost for care.

All Charges