Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Sacroiliac Joints 1 or 2 Views - Report

Professional

Both

$75.00

Service Code	HCPCS 72200 26
Hospital Charge Code	630216
Hospital Revenue Code	972
Min. Negotiated Rate	$8.53
Max. Negotiated Rate	$63.75
Rate for Payer: AlohaCare Medicaid	$22.21
Rate for Payer: AlohaCare Medicare	$8.53
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$9.38
Rate for Payer: Hawaii Medical Service Association Medicare	$8.53
Rate for Payer: Hawaii Western Management Group Commercial	$32.36
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$9.38
Rate for Payer: Kaiser Permanente Medicaid	$9.38
Rate for Payer: Kaiser Permanente Medicare	$9.38
Rate for Payer: Ohana Health Plan Medicaid	$22.21
Rate for Payer: Ohana Health Plan Medicare	$8.53
Rate for Payer: UnitedHealthcare Medicaid	$22.21
Rate for Payer: UnitedHealthcare Medicare	$8.53

XR Sacroiliac Joints 3+ Views

Facility

$554.00

Service Code	HCPCS 72202
Hospital Charge Code	1170387
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$537.38
Rate for Payer: AlohaCare Medicaid	$277.00
Rate for Payer: AlohaCare Medicare	$277.00
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Devoted Health Medicare	$304.70
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$277.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.35
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Humana Medicare	$277.00
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: Kaiser Permanente Medicaid	$282.54
Rate for Payer: Kaiser Permanente Medicare	$277.00
Rate for Payer: MDX Hawaii PPO	$537.38
Rate for Payer: Ohana Health Plan Medicaid	$277.00
Rate for Payer: Ohana Health Plan Medicare	$277.00
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$277.00
Rate for Payer: University Health Alliance Commercial	$71.43

XR Sacroiliac Joints 3+ Views

Facility

$554.00

Service Code	HCPCS 72202
Hospital Charge Code	1170387
Hospital Revenue Code	320
Min. Negotiated Rate	$470.90
Max. Negotiated Rate	$537.38
Rate for Payer: Cash Price	$360.10
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: MDX Hawaii PPO	$537.38

XR Sacroiliac Joints 3+ Views - Report

Professional

Both

$66.00

Service Code	HCPCS 72202 26
Hospital Charge Code	630197
Hospital Revenue Code	972
Min. Negotiated Rate	$10.58
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$26.16
Rate for Payer: AlohaCare Medicare	$10.58
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$11.64
Rate for Payer: Hawaii Medical Service Association Medicare	$10.58
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$11.64
Rate for Payer: Kaiser Permanente Medicaid	$11.64
Rate for Payer: Kaiser Permanente Medicare	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$26.16
Rate for Payer: Ohana Health Plan Medicare	$10.58
Rate for Payer: UnitedHealthcare Medicaid	$26.16
Rate for Payer: UnitedHealthcare Medicare	$10.58

XR Sacrum/Coccyx 2+ Views

Facility

$411.00

Service Code	HCPCS 72220
Hospital Charge Code	1170391
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$398.67
Rate for Payer: AlohaCare Medicaid	$205.50
Rate for Payer: AlohaCare Medicare	$205.50
Rate for Payer: Cash Price	$267.15
Rate for Payer: Cash Price	$267.15
Rate for Payer: Devoted Health Medicare	$226.05
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$205.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Humana Medicare	$205.50
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: Kaiser Permanente Medicaid	$209.61
Rate for Payer: Kaiser Permanente Medicare	$205.50
Rate for Payer: MDX Hawaii PPO	$398.67
Rate for Payer: Ohana Health Plan Medicaid	$205.50
Rate for Payer: Ohana Health Plan Medicare	$205.50
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$205.50
Rate for Payer: University Health Alliance Commercial	$62.01

XR Sacrum/Coccyx 2+ Views

Facility

$411.00

Service Code	HCPCS 72220
Hospital Charge Code	1170391
Hospital Revenue Code	320
Min. Negotiated Rate	$349.35
Max. Negotiated Rate	$398.67
Rate for Payer: Cash Price	$267.15
Rate for Payer: Health Management Network Commercial	$349.35
Rate for Payer: Kaiser Permanente Commercial	$369.90
Rate for Payer: MDX Hawaii PPO	$398.67

XR Sacrum/Coccyx 2+ Views - Report

Professional

Both

$66.00

Service Code	HCPCS 72220 26
Hospital Charge Code	630187
Hospital Revenue Code	972
Min. Negotiated Rate	$8.53
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$21.75
Rate for Payer: AlohaCare Medicare	$8.53
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$9.38
Rate for Payer: Hawaii Medical Service Association Medicare	$8.53
Rate for Payer: Hawaii Western Management Group Commercial	$34.64
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$9.38
Rate for Payer: Kaiser Permanente Medicaid	$9.38
Rate for Payer: Kaiser Permanente Medicare	$9.38
Rate for Payer: Ohana Health Plan Medicaid	$21.75
Rate for Payer: Ohana Health Plan Medicare	$8.53
Rate for Payer: UnitedHealthcare Medicaid	$21.75
Rate for Payer: UnitedHealthcare Medicare	$8.53

XR Scapula Complete Bilateral

Facility

$524.00

Service Code	HCPCS 73010 50
Hospital Charge Code	8207987
Hospital Revenue Code	320
Min. Negotiated Rate	$445.40
Max. Negotiated Rate	$508.28
Rate for Payer: Cash Price	$340.60
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: MDX Hawaii PPO	$508.28

XR Scapula Complete Bilateral

Facility

$524.00

Service Code	HCPCS 73010 50
Hospital Charge Code	8207987
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$508.28
Rate for Payer: AlohaCare Medicaid	$262.00
Rate for Payer: AlohaCare Medicare	$262.00
Rate for Payer: Cash Price	$340.60
Rate for Payer: Cash Price	$340.60
Rate for Payer: Devoted Health Medicare	$288.20
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$497.80
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Humana Medicare	$262.00
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: Kaiser Permanente Medicaid	$267.24
Rate for Payer: Kaiser Permanente Medicare	$262.00
Rate for Payer: MDX Hawaii PPO	$508.28
Rate for Payer: Ohana Health Plan Medicaid	$262.00
Rate for Payer: Ohana Health Plan Medicare	$262.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$262.00
Rate for Payer: University Health Alliance Commercial	$58.59

XR Scapula Complete Bilateral - Report

Professional

Both

$145.00

Service Code	HCPCS 73010 26,50
Hospital Charge Code	8207989
Hospital Revenue Code	972
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$15.78
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$32.36
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$15.78
Rate for Payer: UnitedHealthcare Medicaid	$15.78

XR Scapula Left

Facility

$524.00

Service Code	HCPCS 73010 LT
Hospital Charge Code	1170401
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$508.28
Rate for Payer: AlohaCare Medicaid	$262.00
Rate for Payer: AlohaCare Medicare	$262.00
Rate for Payer: Cash Price	$340.60
Rate for Payer: Cash Price	$340.60
Rate for Payer: Devoted Health Medicare	$288.20
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$497.80
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Humana Medicare	$262.00
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: Kaiser Permanente Medicaid	$267.24
Rate for Payer: Kaiser Permanente Medicare	$262.00
Rate for Payer: MDX Hawaii PPO	$508.28
Rate for Payer: Ohana Health Plan Medicaid	$262.00
Rate for Payer: Ohana Health Plan Medicare	$262.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$262.00
Rate for Payer: University Health Alliance Commercial	$58.59

XR Scapula Left

Facility

$524.00

Service Code	HCPCS 73010 LT
Hospital Charge Code	1170401
Hospital Revenue Code	320
Min. Negotiated Rate	$445.40
Max. Negotiated Rate	$508.28
Rate for Payer: Cash Price	$340.60
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: MDX Hawaii PPO	$508.28

XR Scapula Left - Report

Professional

Both

$70.00

Service Code	HCPCS 73010 26,LT
Hospital Charge Code	630167
Hospital Revenue Code	972
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$15.78
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$32.36
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$15.78
Rate for Payer: UnitedHealthcare Medicaid	$15.78

XR Scapula Right

Facility

$524.00

Service Code	HCPCS 73010 RT
Hospital Charge Code	1170403
Hospital Revenue Code	320
Min. Negotiated Rate	$445.40
Max. Negotiated Rate	$508.28
Rate for Payer: Cash Price	$340.60
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: MDX Hawaii PPO	$508.28

XR Scapula Right

Facility

$524.00

Service Code	HCPCS 73010 RT
Hospital Charge Code	1170403
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$508.28
Rate for Payer: AlohaCare Medicaid	$262.00
Rate for Payer: AlohaCare Medicare	$262.00
Rate for Payer: Cash Price	$340.60
Rate for Payer: Cash Price	$340.60
Rate for Payer: Devoted Health Medicare	$288.20
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$497.80
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Humana Medicare	$262.00
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: Kaiser Permanente Medicaid	$267.24
Rate for Payer: Kaiser Permanente Medicare	$262.00
Rate for Payer: MDX Hawaii PPO	$508.28
Rate for Payer: Ohana Health Plan Medicaid	$262.00
Rate for Payer: Ohana Health Plan Medicare	$262.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$262.00
Rate for Payer: University Health Alliance Commercial	$58.59

XR Scapula Right - Report

Professional

Both

$70.00

Service Code	HCPCS 73010 26,RT
Hospital Charge Code	630163
Hospital Revenue Code	972
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$15.78
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$32.36
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$15.78
Rate for Payer: UnitedHealthcare Medicaid	$15.78

XR Sella Turcica

Facility

$319.00

Service Code	HCPCS 70240
Hospital Charge Code	1170405
Hospital Revenue Code	320
Min. Negotiated Rate	$271.15
Max. Negotiated Rate	$309.43
Rate for Payer: Cash Price	$207.35
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: MDX Hawaii PPO	$309.43

XR Sella Turcica

Facility

$319.00

Service Code	HCPCS 70240
Hospital Charge Code	1170405
Hospital Revenue Code	320
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$309.43
Rate for Payer: AlohaCare Medicaid	$159.50
Rate for Payer: AlohaCare Medicare	$159.50
Rate for Payer: Cash Price	$207.35
Rate for Payer: Cash Price	$207.35
Rate for Payer: Devoted Health Medicare	$175.45
Rate for Payer: Hawaii Medical Service Association ABD	$13.91
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$159.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.15
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Humana Medicare	$159.50
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: Kaiser Permanente Medicaid	$162.69
Rate for Payer: Kaiser Permanente Medicare	$159.50
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: Ohana Health Plan Medicaid	$159.50
Rate for Payer: Ohana Health Plan Medicare	$159.50
Rate for Payer: UnitedHealthcare Medicaid	$13.91
Rate for Payer: UnitedHealthcare Medicare	$159.50
Rate for Payer: University Health Alliance Commercial	$56.80

XR Sella Turcica - Report

Professional

Both

$80.00

Service Code	HCPCS 70240 26
Hospital Charge Code	630157
Hospital Revenue Code	972
Min. Negotiated Rate	$9.20
Max. Negotiated Rate	$68.00
Rate for Payer: AlohaCare Medicaid	$21.92
Rate for Payer: AlohaCare Medicare	$9.20
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cash Price	$52.00
Rate for Payer: Devoted Health Medicare	$10.12
Rate for Payer: Hawaii Medical Service Association Medicare	$9.20
Rate for Payer: Hawaii Western Management Group Commercial	$28.95
Rate for Payer: Health Management Network Commercial	$68.00
Rate for Payer: Kaiser Permanente Commercial	$10.12
Rate for Payer: Kaiser Permanente Medicaid	$10.12
Rate for Payer: Kaiser Permanente Medicare	$10.12
Rate for Payer: Ohana Health Plan Medicaid	$21.92
Rate for Payer: Ohana Health Plan Medicare	$9.20
Rate for Payer: UnitedHealthcare Medicaid	$21.92
Rate for Payer: UnitedHealthcare Medicare	$9.20

XR Shoulder 1 View Left

Facility

$397.00

Service Code	HCPCS 73020 LT
Hospital Charge Code	1170409
Hospital Revenue Code	320
Min. Negotiated Rate	$337.45
Max. Negotiated Rate	$385.09
Rate for Payer: Cash Price	$258.05
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: MDX Hawaii PPO	$385.09

XR Shoulder 1 View Left

Facility

$397.00

Service Code	HCPCS 73020 LT
Hospital Charge Code	1170409
Hospital Revenue Code	320
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$385.09
Rate for Payer: AlohaCare Medicaid	$198.50
Rate for Payer: AlohaCare Medicare	$198.50
Rate for Payer: Cash Price	$258.05
Rate for Payer: Cash Price	$258.05
Rate for Payer: Devoted Health Medicare	$218.35
Rate for Payer: Hawaii Medical Service Association ABD	$15.78
Rate for Payer: Hawaii Medical Service Association Medicare	$198.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.87
Rate for Payer: Hawaii Western Management Group Commercial	$377.15
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Humana Medicare	$198.50
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: Kaiser Permanente Medicaid	$202.47
Rate for Payer: Kaiser Permanente Medicare	$198.50
Rate for Payer: MDX Hawaii PPO	$385.09
Rate for Payer: Ohana Health Plan Medicaid	$198.50
Rate for Payer: Ohana Health Plan Medicare	$198.50
Rate for Payer: UnitedHealthcare Medicaid	$15.78
Rate for Payer: UnitedHealthcare Medicare	$198.50
Rate for Payer: University Health Alliance Commercial	$49.15

XR Shoulder 1 View Left - Report

Professional

Both

$58.00

Service Code	HCPCS 73020 26,LT
Hospital Charge Code	630147
Hospital Revenue Code	972
Min. Negotiated Rate	$14.24
Max. Negotiated Rate	$49.30
Rate for Payer: AlohaCare Medicaid	$14.24
Rate for Payer: Cash Price	$37.70
Rate for Payer: Cash Price	$37.70
Rate for Payer: Hawaii Western Management Group Commercial	$29.20
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Ohana Health Plan Medicaid	$14.24
Rate for Payer: UnitedHealthcare Medicaid	$14.24

XR Shoulder 1 View Right

Facility

$397.00

Service Code	HCPCS 73020 RT
Hospital Charge Code	1170411
Hospital Revenue Code	320
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$385.09
Rate for Payer: AlohaCare Medicaid	$198.50
Rate for Payer: AlohaCare Medicare	$198.50
Rate for Payer: Cash Price	$258.05
Rate for Payer: Cash Price	$258.05
Rate for Payer: Devoted Health Medicare	$218.35
Rate for Payer: Hawaii Medical Service Association ABD	$15.78
Rate for Payer: Hawaii Medical Service Association Medicare	$198.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.87
Rate for Payer: Hawaii Western Management Group Commercial	$377.15
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Humana Medicare	$198.50
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: Kaiser Permanente Medicaid	$202.47
Rate for Payer: Kaiser Permanente Medicare	$198.50
Rate for Payer: MDX Hawaii PPO	$385.09
Rate for Payer: Ohana Health Plan Medicaid	$198.50
Rate for Payer: Ohana Health Plan Medicare	$198.50
Rate for Payer: UnitedHealthcare Medicaid	$15.78
Rate for Payer: UnitedHealthcare Medicare	$198.50
Rate for Payer: University Health Alliance Commercial	$49.15

XR Shoulder 1 View Right

Facility

$397.00

Service Code	HCPCS 73020 RT
Hospital Charge Code	1170411
Hospital Revenue Code	320
Min. Negotiated Rate	$337.45
Max. Negotiated Rate	$385.09
Rate for Payer: Cash Price	$258.05
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: MDX Hawaii PPO	$385.09

XR Shoulder 1 View Right - Report

Professional

Both

$58.00

Service Code	HCPCS 73020 26,RT
Hospital Charge Code	630143
Hospital Revenue Code	972
Min. Negotiated Rate	$14.24
Max. Negotiated Rate	$49.30
Rate for Payer: AlohaCare Medicaid	$14.24
Rate for Payer: Cash Price	$37.70
Rate for Payer: Cash Price	$37.70
Rate for Payer: Hawaii Western Management Group Commercial	$29.20
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Ohana Health Plan Medicaid	$14.24
Rate for Payer: UnitedHealthcare Medicaid	$14.24

Know your out-of-pocket cost for care.

All Charges