Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Knee 3 Views Bilateral

Facility

$525.00

Service Code	HCPCS 73562 50
Hospital Charge Code	1170267
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	$68.32

XR Knee 3 Views Bilateral - Report

Professional

Both

$72.00

Service Code	HCPCS 73562 26,50
Hospital Charge Code	630416
Hospital Revenue Code	972
Min. Negotiated Rate	$27.46
Max. Negotiated Rate	$61.20
Rate for Payer: AlohaCare Medicaid	$27.46
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$35.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Ohana Health Plan Medicaid	$27.46
Rate for Payer: UnitedHealthcare Medicaid	$27.46

XR Knee 3 Views Left

Facility

$525.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	1170269
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	$68.32

XR Knee 3 Views Left

Facility

$525.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	1170269
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 Knee 3 Views Left - Report

Professional

Both

$72.00

Service Code	HCPCS 73562 26,LT
Hospital Charge Code	630404
Hospital Revenue Code	972
Min. Negotiated Rate	$27.46
Max. Negotiated Rate	$61.20
Rate for Payer: AlohaCare Medicaid	$27.46
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$35.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Ohana Health Plan Medicaid	$27.46
Rate for Payer: UnitedHealthcare Medicaid	$27.46

XR Knee 3 Views Right

Facility

$525.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	1170271
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	$68.32

XR Knee 3 Views Right

Facility

$525.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	1170271
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 Knee 3 Views Right - Report

Professional

Both

$72.00

Service Code	HCPCS 73562 26,RT
Hospital Charge Code	630396
Hospital Revenue Code	972
Min. Negotiated Rate	$27.46
Max. Negotiated Rate	$61.20
Rate for Payer: AlohaCare Medicaid	$27.46
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$35.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Ohana Health Plan Medicaid	$27.46
Rate for Payer: UnitedHealthcare Medicaid	$27.46

XR Knee Complete 4+ Views Bilateral

Facility

$859.00

Service Code	HCPCS 73564 50
Hospital Charge Code	1170285
Hospital Revenue Code	320
Min. Negotiated Rate	$730.15
Max. Negotiated Rate	$833.23
Rate for Payer: Cash Price	$558.35
Rate for Payer: Health Management Network Commercial	$730.15
Rate for Payer: Kaiser Permanente Commercial	$773.10
Rate for Payer: MDX Hawaii PPO	$833.23

XR Knee Complete 4+ Views Bilateral

Facility

$859.00

Service Code	HCPCS 73564 50
Hospital Charge Code	1170285
Hospital Revenue Code	320
Min. Negotiated Rate	$22.13
Max. Negotiated Rate	$833.23
Rate for Payer: AlohaCare Medicaid	$429.50
Rate for Payer: AlohaCare Medicare	$429.50
Rate for Payer: Cash Price	$558.35
Rate for Payer: Cash Price	$558.35
Rate for Payer: Devoted Health Medicare	$472.45
Rate for Payer: Hawaii Medical Service Association ABD	$22.13
Rate for Payer: Hawaii Medical Service Association Medicare	$429.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.24
Rate for Payer: Hawaii Western Management Group Commercial	$816.05
Rate for Payer: Health Management Network Commercial	$730.15
Rate for Payer: Humana Medicare	$429.50
Rate for Payer: Kaiser Permanente Commercial	$773.10
Rate for Payer: Kaiser Permanente Medicaid	$438.09
Rate for Payer: Kaiser Permanente Medicare	$429.50
Rate for Payer: MDX Hawaii PPO	$833.23
Rate for Payer: Ohana Health Plan Medicaid	$429.50
Rate for Payer: Ohana Health Plan Medicare	$429.50
Rate for Payer: UnitedHealthcare Medicaid	$22.13
Rate for Payer: UnitedHealthcare Medicare	$429.50
Rate for Payer: University Health Alliance Commercial	$77.64

XR Knee Complete 4+ Views Bilateral - Report

Professional

Both

$86.00

Service Code	HCPCS 73564 26,50
Hospital Charge Code	630392
Hospital Revenue Code	972
Min. Negotiated Rate	$31.70
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$31.70
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Hawaii Western Management Group Commercial	$39.59
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Ohana Health Plan Medicaid	$31.70
Rate for Payer: UnitedHealthcare Medicaid	$31.70

XR Knee Complete 4+ Views Left

Facility

$864.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	1170287
Hospital Revenue Code	320
Min. Negotiated Rate	$734.40
Max. Negotiated Rate	$838.08
Rate for Payer: Cash Price	$561.60
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: MDX Hawaii PPO	$838.08

XR Knee Complete 4+ Views Left

Facility

$864.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	1170287
Hospital Revenue Code	320
Min. Negotiated Rate	$22.13
Max. Negotiated Rate	$838.08
Rate for Payer: AlohaCare Medicaid	$432.00
Rate for Payer: AlohaCare Medicare	$432.00
Rate for Payer: Cash Price	$561.60
Rate for Payer: Cash Price	$561.60
Rate for Payer: Devoted Health Medicare	$475.20
Rate for Payer: Hawaii Medical Service Association ABD	$22.13
Rate for Payer: Hawaii Medical Service Association Medicare	$432.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.24
Rate for Payer: Hawaii Western Management Group Commercial	$820.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Humana Medicare	$432.00
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: Kaiser Permanente Medicaid	$440.64
Rate for Payer: Kaiser Permanente Medicare	$432.00
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: Ohana Health Plan Medicaid	$432.00
Rate for Payer: Ohana Health Plan Medicare	$432.00
Rate for Payer: UnitedHealthcare Medicaid	$22.13
Rate for Payer: UnitedHealthcare Medicare	$432.00
Rate for Payer: University Health Alliance Commercial	$77.64

XR Knee Complete 4+ Views Left - Report

Professional

Both

$86.00

Service Code	HCPCS 73564 26,LT
Hospital Charge Code	630374
Hospital Revenue Code	972
Min. Negotiated Rate	$31.70
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$31.70
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Hawaii Western Management Group Commercial	$39.59
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Ohana Health Plan Medicaid	$31.70
Rate for Payer: UnitedHealthcare Medicaid	$31.70

XR Knee Complete 4+ Views Right

Facility

$864.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	1170289
Hospital Revenue Code	320
Min. Negotiated Rate	$22.13
Max. Negotiated Rate	$838.08
Rate for Payer: AlohaCare Medicaid	$432.00
Rate for Payer: AlohaCare Medicare	$432.00
Rate for Payer: Cash Price	$561.60
Rate for Payer: Cash Price	$561.60
Rate for Payer: Devoted Health Medicare	$475.20
Rate for Payer: Hawaii Medical Service Association ABD	$22.13
Rate for Payer: Hawaii Medical Service Association Medicare	$432.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.24
Rate for Payer: Hawaii Western Management Group Commercial	$820.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Humana Medicare	$432.00
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: Kaiser Permanente Medicaid	$440.64
Rate for Payer: Kaiser Permanente Medicare	$432.00
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: Ohana Health Plan Medicaid	$432.00
Rate for Payer: Ohana Health Plan Medicare	$432.00
Rate for Payer: UnitedHealthcare Medicaid	$22.13
Rate for Payer: UnitedHealthcare Medicare	$432.00
Rate for Payer: University Health Alliance Commercial	$77.64

XR Knee Complete 4+ Views Right

Facility

$864.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	1170289
Hospital Revenue Code	320
Min. Negotiated Rate	$734.40
Max. Negotiated Rate	$838.08
Rate for Payer: Cash Price	$561.60
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: MDX Hawaii PPO	$838.08

XR Knee Complete 4+ Views Right - Report

Professional

Both

$86.00

Service Code	HCPCS 73564 26,RT
Hospital Charge Code	630370
Hospital Revenue Code	972
Min. Negotiated Rate	$31.70
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$31.70
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Hawaii Western Management Group Commercial	$39.59
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Ohana Health Plan Medicaid	$31.70
Rate for Payer: UnitedHealthcare Medicaid	$31.70

XR Lower Extremity Infant (0-1yr) Bilat

Facility

$381.00

Service Code	HCPCS 73592 50
Hospital Charge Code	1170295
Hospital Revenue Code	320
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$247.65
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: MDX Hawaii PPO	$369.57

XR Lower Extremity Infant (0-1yr) Bilat

Facility

$381.00

Service Code	HCPCS 73592 50
Hospital Charge Code	1170295
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$369.57
Rate for Payer: Ohana Health Plan Medicaid	$190.50
Rate for Payer: AlohaCare Medicaid	$190.50
Rate for Payer: AlohaCare Medicare	$190.50
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Devoted Health Medicare	$209.55
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$190.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$361.95
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Humana Medicare	$190.50
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: Kaiser Permanente Medicare	$190.50
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: Ohana Health Plan Medicare	$190.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$190.50
Rate for Payer: University Health Alliance Commercial	$56.28

XR Lower Extremity Infant (0-1yr) Bilat - Report

Professional

Both

$86.00

Service Code	HCPCS 73592 26,50
Hospital Charge Code	630346
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 Lower Extremity Infant (0-1yr) Left

Facility

$381.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	1170297
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$369.57
Rate for Payer: AlohaCare Medicaid	$190.50
Rate for Payer: AlohaCare Medicare	$190.50
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Devoted Health Medicare	$209.55
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$190.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$361.95
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Humana Medicare	$190.50
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: Kaiser Permanente Medicare	$190.50
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: Ohana Health Plan Medicaid	$190.50
Rate for Payer: Ohana Health Plan Medicare	$190.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$190.50
Rate for Payer: University Health Alliance Commercial	$56.28

XR Lower Extremity Infant (0-1yr) Left

Facility

$381.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	1170297
Hospital Revenue Code	320
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$247.65
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: MDX Hawaii PPO	$369.57

XR Lower Extremity Infant (0-1yr) Left - Report

Professional

Both

$86.00

Service Code	HCPCS 73592 26,LT
Hospital Charge Code	630344
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 Lower Extremity Infant (0-1yr) Right

Facility

$381.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	1170299
Hospital Revenue Code	320
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$247.65
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: MDX Hawaii PPO	$369.57

XR Lower Extremity Infant (0-1yr) Right

Facility

$381.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	1170299
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$369.57
Rate for Payer: AlohaCare Medicaid	$190.50
Rate for Payer: AlohaCare Medicare	$190.50
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Devoted Health Medicare	$209.55
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$190.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$361.95
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Humana Medicare	$190.50
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: Kaiser Permanente Medicare	$190.50
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: Ohana Health Plan Medicaid	$190.50
Rate for Payer: Ohana Health Plan Medicare	$190.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$190.50
Rate for Payer: University Health Alliance Commercial	$56.28

Know your out-of-pocket cost for care.

All Charges