Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Humerus Right

Facility

$440.00

Service Code	HCPCS 73060 RT
Hospital Charge Code	1170247
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 Right - Report

Professional

Both

$66.00

Service Code	HCPCS 73060 26,RT
Hospital Charge Code	630428
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 Hysterosalpingography

Facility

$1,068.00

Service Code	HCPCS 74740
Hospital Charge Code	1170249
Hospital Revenue Code	320
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$1,035.96
Rate for Payer: AlohaCare Medicaid	$534.00
Rate for Payer: AlohaCare Medicare	$534.00
Rate for Payer: Cash Price	$694.20
Rate for Payer: Cash Price	$694.20
Rate for Payer: Devoted Health Medicare	$587.40
Rate for Payer: Hawaii Medical Service Association ABD	$42.98
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$534.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.81
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$907.80
Rate for Payer: Humana Medicare	$534.00
Rate for Payer: Kaiser Permanente Commercial	$961.20
Rate for Payer: Kaiser Permanente Medicaid	$544.68
Rate for Payer: Kaiser Permanente Medicare	$534.00
Rate for Payer: MDX Hawaii PPO	$1,035.96
Rate for Payer: Ohana Health Plan Medicaid	$534.00
Rate for Payer: Ohana Health Plan Medicare	$534.00
Rate for Payer: UnitedHealthcare Medicaid	$42.98
Rate for Payer: UnitedHealthcare Medicare	$534.00
Rate for Payer: University Health Alliance Commercial	$156.07

XR Hysterosalpingography

Facility

$1,068.00

Service Code	HCPCS 74740
Hospital Charge Code	1170249
Hospital Revenue Code	320
Min. Negotiated Rate	$907.80
Max. Negotiated Rate	$1,035.96
Rate for Payer: Cash Price	$694.20
Rate for Payer: Health Management Network Commercial	$907.80
Rate for Payer: Kaiser Permanente Commercial	$961.20
Rate for Payer: MDX Hawaii PPO	$1,035.96

XR Hysterosalpingography - Report

Professional

Both

$138.00

Service Code	HCPCS 74740 26
Hospital Charge Code	630426
Hospital Revenue Code	972
Min. Negotiated Rate	$18.06
Max. Negotiated Rate	$117.30
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$18.06
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$19.87
Rate for Payer: Hawaii Medical Service Association Medicare	$18.06
Rate for Payer: Hawaii Western Management Group Commercial	$77.76
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$19.87
Rate for Payer: Kaiser Permanente Medicaid	$19.87
Rate for Payer: Kaiser Permanente Medicare	$19.87
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$18.06
Rate for Payer: UnitedHealthcare Medicaid	$63.00
Rate for Payer: UnitedHealthcare Medicare	$18.06

XR Insertion Straight Bladder Catheter

Facility

$1,279.00

Service Code	HCPCS 10030
Hospital Charge Code	2425542
Hospital Revenue Code	361
Min. Negotiated Rate	$1,087.15
Max. Negotiated Rate	$1,240.63
Rate for Payer: Cash Price	$831.35
Rate for Payer: Health Management Network Commercial	$1,087.15
Rate for Payer: Kaiser Permanente Commercial	$1,151.10
Rate for Payer: MDX Hawaii PPO	$1,240.63

XR Insertion Straight Bladder Catheter

Facility

$1,279.00

Service Code	HCPCS 10030
Hospital Charge Code	2425542
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$639.50
Rate for Payer: AlohaCare Medicare	$639.50
Rate for Payer: Cash Price	$831.35
Rate for Payer: Cash Price	$831.35
Rate for Payer: Devoted Health Medicare	$703.45
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$639.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$1,087.15
Rate for Payer: Humana Medicare	$639.50
Rate for Payer: Kaiser Permanente Commercial	$1,151.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$639.50
Rate for Payer: MDX Hawaii PPO	$1,240.63
Rate for Payer: Ohana Health Plan Medicaid	$639.50
Rate for Payer: Ohana Health Plan Medicare	$639.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$639.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

XR Joint/Bursa Major Arthr/Asp/Inj Left

Facility

$707.00

Service Code	HCPCS 20610 LT
Hospital Charge Code	2425554
Hospital Revenue Code	361
Min. Negotiated Rate	$600.95
Max. Negotiated Rate	$685.79
Rate for Payer: Cash Price	$459.55
Rate for Payer: Health Management Network Commercial	$600.95
Rate for Payer: Kaiser Permanente Commercial	$636.30
Rate for Payer: MDX Hawaii PPO	$685.79

XR Joint/Bursa Major Arthr/Asp/Inj Left

Facility

$707.00

Service Code	HCPCS 20610 LT
Hospital Charge Code	2425554
Hospital Revenue Code	361
Min. Negotiated Rate	$48.79
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$353.50
Rate for Payer: AlohaCare Medicare	$353.50
Rate for Payer: Cash Price	$459.55
Rate for Payer: Cash Price	$459.55
Rate for Payer: Cash Price	$459.55
Rate for Payer: Devoted Health Medicare	$388.85
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$353.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$600.95
Rate for Payer: Humana Medicare	$353.50
Rate for Payer: Kaiser Permanente Commercial	$636.30
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$353.50
Rate for Payer: MDX Hawaii PPO	$685.79
Rate for Payer: Ohana Health Plan Medicaid	$353.50
Rate for Payer: Ohana Health Plan Medicare	$353.50
Rate for Payer: UnitedHealthcare Medicaid	$48.79
Rate for Payer: UnitedHealthcare Medicare	$353.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

XR Joint/Bursa Major Arthr/Asp/Inj Left - Report

Professional

Both

$427.00

Service Code	HCPCS 20610 26,LT
Hospital Charge Code	2425556
Hospital Revenue Code	972
Min. Negotiated Rate	$45.55
Max. Negotiated Rate	$362.95
Rate for Payer: AlohaCare Medicaid	$45.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Hawaii Medical Service Association ABD	$45.55
Rate for Payer: Hawaii Medical Service Association Commercial	$75.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$45.55
Rate for Payer: Hawaii Western Management Group Commercial	$58.76
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Ohana Health Plan Medicaid	$45.55
Rate for Payer: UnitedHealthcare Medicaid	$45.55

XR Joint/Bursa Major Arthr/Asp/Inj Right

Facility

$707.00

Service Code	HCPCS 20610 RT
Hospital Charge Code	2425557
Hospital Revenue Code	361
Min. Negotiated Rate	$48.79
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$353.50
Rate for Payer: AlohaCare Medicare	$353.50
Rate for Payer: Cash Price	$459.55
Rate for Payer: Cash Price	$459.55
Rate for Payer: Cash Price	$459.55
Rate for Payer: Devoted Health Medicare	$388.85
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$353.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$600.95
Rate for Payer: Humana Medicare	$353.50
Rate for Payer: Kaiser Permanente Commercial	$636.30
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$353.50
Rate for Payer: MDX Hawaii PPO	$685.79
Rate for Payer: Ohana Health Plan Medicaid	$353.50
Rate for Payer: Ohana Health Plan Medicare	$353.50
Rate for Payer: UnitedHealthcare Medicaid	$48.79
Rate for Payer: UnitedHealthcare Medicare	$353.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

XR Joint/Bursa Major Arthr/Asp/Inj Right

Facility

$707.00

Service Code	HCPCS 20610 RT
Hospital Charge Code	2425557
Hospital Revenue Code	361
Min. Negotiated Rate	$600.95
Max. Negotiated Rate	$685.79
Rate for Payer: Cash Price	$459.55
Rate for Payer: Health Management Network Commercial	$600.95
Rate for Payer: Kaiser Permanente Commercial	$636.30
Rate for Payer: MDX Hawaii PPO	$685.79

XR Joint Survey Single View 2+ Joints

Facility

$419.00

Service Code	HCPCS 77077
Hospital Charge Code	1170259
Hospital Revenue Code	320
Min. Negotiated Rate	$29.89
Max. Negotiated Rate	$406.43
Rate for Payer: AlohaCare Medicaid	$209.50
Rate for Payer: AlohaCare Medicare	$209.50
Rate for Payer: Cash Price	$272.35
Rate for Payer: Cash Price	$272.35
Rate for Payer: Devoted Health Medicare	$230.45
Rate for Payer: Hawaii Medical Service Association ABD	$29.89
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$209.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.34
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Humana Medicare	$209.50
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: Kaiser Permanente Medicaid	$213.69
Rate for Payer: Kaiser Permanente Medicare	$209.50
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: Ohana Health Plan Medicaid	$209.50
Rate for Payer: Ohana Health Plan Medicare	$209.50
Rate for Payer: UnitedHealthcare Medicaid	$29.89
Rate for Payer: UnitedHealthcare Medicare	$209.50
Rate for Payer: University Health Alliance Commercial	$97.64

XR Joint Survey Single View 2+ Joints

Facility

$419.00

Service Code	HCPCS 77077
Hospital Charge Code	1170259
Hospital Revenue Code	320
Min. Negotiated Rate	$356.15
Max. Negotiated Rate	$406.43
Rate for Payer: Cash Price	$272.35
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: MDX Hawaii PPO	$406.43

XR Joint Survey Single View 2+ Joints - Report

Professional

Both

$128.00

Service Code	HCPCS 77077 26
Hospital Charge Code	630412
Hospital Revenue Code	972
Min. Negotiated Rate	$16.77
Max. Negotiated Rate	$108.80
Rate for Payer: AlohaCare Medicaid	$31.02
Rate for Payer: AlohaCare Medicare	$16.77
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$18.45
Rate for Payer: Hawaii Medical Service Association Medicare	$16.77
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$18.45
Rate for Payer: Kaiser Permanente Medicaid	$18.45
Rate for Payer: Kaiser Permanente Medicare	$18.45
Rate for Payer: Ohana Health Plan Medicaid	$31.02
Rate for Payer: Ohana Health Plan Medicare	$16.77
Rate for Payer: UnitedHealthcare Medicaid	$31.02
Rate for Payer: UnitedHealthcare Medicare	$16.77

XR Knee 1 or 2 Views Bilateral

Facility

$565.00

Service Code	HCPCS 73560 50
Hospital Charge Code	1170261
Hospital Revenue Code	320
Min. Negotiated Rate	$480.25
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$367.25
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: MDX Hawaii PPO	$548.05

XR Knee 1 or 2 Views Bilateral

Facility

$565.00

Service Code	HCPCS 73560 50
Hospital Charge Code	1170261
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$548.05
Rate for Payer: AlohaCare Medicaid	$282.50
Rate for Payer: AlohaCare Medicare	$282.50
Rate for Payer: Cash Price	$367.25
Rate for Payer: Cash Price	$367.25
Rate for Payer: Devoted Health Medicare	$310.75
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$282.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$536.75
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Humana Medicare	$282.50
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: Kaiser Permanente Medicaid	$288.15
Rate for Payer: Kaiser Permanente Medicare	$282.50
Rate for Payer: MDX Hawaii PPO	$548.05
Rate for Payer: Ohana Health Plan Medicaid	$282.50
Rate for Payer: Ohana Health Plan Medicare	$282.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$282.50
Rate for Payer: University Health Alliance Commercial	$58.59

XR Knee 1 or 2 Views Bilateral - Report

Professional

Both

$94.00

Service Code	HCPCS 73560 26,50
Hospital Charge Code	630366
Hospital Revenue Code	972
Min. Negotiated Rate	$22.93
Max. Negotiated Rate	$79.90
Rate for Payer: AlohaCare Medicaid	$22.93
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Hawaii Western Management Group Commercial	$32.16
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Ohana Health Plan Medicaid	$22.93
Rate for Payer: UnitedHealthcare Medicaid	$22.93

XR Knee 1 or 2 Views Left

Facility

$565.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	1170263
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$548.05
Rate for Payer: AlohaCare Medicaid	$282.50
Rate for Payer: AlohaCare Medicare	$282.50
Rate for Payer: Cash Price	$367.25
Rate for Payer: Cash Price	$367.25
Rate for Payer: Devoted Health Medicare	$310.75
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$282.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$536.75
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Humana Medicare	$282.50
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: Kaiser Permanente Medicaid	$288.15
Rate for Payer: Kaiser Permanente Medicare	$282.50
Rate for Payer: MDX Hawaii PPO	$548.05
Rate for Payer: Ohana Health Plan Medicaid	$282.50
Rate for Payer: Ohana Health Plan Medicare	$282.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$282.50
Rate for Payer: University Health Alliance Commercial	$58.59

XR Knee 1 or 2 Views Left

Facility

$565.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	1170263
Hospital Revenue Code	320
Min. Negotiated Rate	$480.25
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$367.25
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: MDX Hawaii PPO	$548.05

XR Knee 1 or 2 Views Left - Report

Professional

Both

$70.00

Service Code	HCPCS 73560 26,LT
Hospital Charge Code	630362
Hospital Revenue Code	972
Min. Negotiated Rate	$22.93
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$22.93
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$32.16
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$22.93
Rate for Payer: UnitedHealthcare Medicaid	$22.93

XR Knee 1 or 2 Views Right

Facility

$565.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	1170265
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$548.05
Rate for Payer: UnitedHealthcare Medicare	$282.50
Rate for Payer: AlohaCare Medicaid	$282.50
Rate for Payer: AlohaCare Medicare	$282.50
Rate for Payer: Cash Price	$367.25
Rate for Payer: Cash Price	$367.25
Rate for Payer: Devoted Health Medicare	$310.75
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$282.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$536.75
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Humana Medicare	$282.50
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: Kaiser Permanente Medicaid	$288.15
Rate for Payer: Kaiser Permanente Medicare	$282.50
Rate for Payer: MDX Hawaii PPO	$548.05
Rate for Payer: Ohana Health Plan Medicaid	$282.50
Rate for Payer: Ohana Health Plan Medicare	$282.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: University Health Alliance Commercial	$58.59

XR Knee 1 or 2 Views Right

Facility

$565.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	1170265
Hospital Revenue Code	320
Min. Negotiated Rate	$480.25
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$367.25
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: MDX Hawaii PPO	$548.05

XR Knee 1 or 2 Views Right - Report

Professional

Both

$70.00

Service Code	HCPCS 73560 26,RT
Hospital Charge Code	630357
Hospital Revenue Code	972
Min. Negotiated Rate	$22.93
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$22.93
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$32.16
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$22.93
Rate for Payer: UnitedHealthcare Medicaid	$22.93

XR Knee 3 Views Bilateral

Facility

$525.00

Service Code	HCPCS 73562 50
Hospital Charge Code	1170267
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

Know your out-of-pocket cost for care.

All Charges