Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Shoulder Complete 2+ Views Bilat

Facility

$525.00

Service Code	HCPCS 73030 50
Hospital Charge Code	8211707
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	$61.92

XR Shoulder Complete 2+ Views Bilat

Facility

$525.00

Service Code	HCPCS 73030 50
Hospital Charge Code	8211707
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 Shoulder Complete 2+ Views Bilat - Report

Professional

Both

$121.00

Service Code	HCPCS 73030 26,50
Hospital Charge Code	8211709
Hospital Revenue Code	972
Min. Negotiated Rate	$23.33
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$23.33
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$23.33
Rate for Payer: UnitedHealthcare Medicaid	$23.33

XR Shoulder Complete 2+ Views Left

Facility

$525.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	1170415
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	$61.92

XR Shoulder Complete 2+ Views Left

Facility

$525.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	1170415
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 Shoulder Complete 2+ Views Left - Report

Professional

Both

$72.00

Service Code	HCPCS 73030 26,LT
Hospital Charge Code	630127
Hospital Revenue Code	972
Min. Negotiated Rate	$23.33
Max. Negotiated Rate	$61.20
Rate for Payer: AlohaCare Medicaid	$23.33
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Ohana Health Plan Medicaid	$23.33
Rate for Payer: UnitedHealthcare Medicaid	$23.33

XR Shoulder Complete 2+ Views Right

Facility

$525.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	1170417
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 Shoulder Complete 2+ Views Right

Facility

$525.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	1170417
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	$61.92

XR Shoulder Complete 2+ Views Right - Report

Professional

Both

$72.00

Service Code	HCPCS 73030 26,RT
Hospital Charge Code	630123
Hospital Revenue Code	972
Min. Negotiated Rate	$23.33
Max. Negotiated Rate	$61.20
Rate for Payer: AlohaCare Medicaid	$23.33
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Ohana Health Plan Medicaid	$23.33
Rate for Payer: UnitedHealthcare Medicaid	$23.33

XR Sialogram

Facility

$740.00

Service Code	HCPCS 70390
Hospital Charge Code	1170430
Hospital Revenue Code	320
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

XR Sialogram

Facility

$740.00

Service Code	HCPCS 70390
Hospital Charge Code	1170430
Hospital Revenue Code	320
Min. Negotiated Rate	$59.03
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$59.03
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$63.93
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$59.03
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$200.58

XR Sialogram - Report

Professional

Both

$222.00

Service Code	HCPCS 70390 26
Hospital Charge Code	630111
Hospital Revenue Code	972
Min. Negotiated Rate	$17.68
Max. Negotiated Rate	$188.70
Rate for Payer: AlohaCare Medicaid	$78.15
Rate for Payer: AlohaCare Medicare	$17.68
Rate for Payer: Cash Price	$144.30
Rate for Payer: Cash Price	$144.30
Rate for Payer: Devoted Health Medicare	$19.45
Rate for Payer: Hawaii Medical Service Association Medicare	$17.68
Rate for Payer: Hawaii Western Management Group Commercial	$99.09
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Kaiser Permanente Commercial	$19.45
Rate for Payer: Kaiser Permanente Medicaid	$19.45
Rate for Payer: Kaiser Permanente Medicare	$19.45
Rate for Payer: Ohana Health Plan Medicaid	$78.15
Rate for Payer: Ohana Health Plan Medicare	$17.68
Rate for Payer: UnitedHealthcare Medicaid	$78.15
Rate for Payer: UnitedHealthcare Medicare	$17.68

XR Sinuses Paranasal < 3 Views

Facility

$524.00

Service Code	HCPCS 70210
Hospital Charge Code	1170432
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
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	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.35
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
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	$20.40
Rate for Payer: UnitedHealthcare Medicare	$262.00
Rate for Payer: University Health Alliance Commercial	$62.81

XR Sinuses Paranasal < 3 Views

Facility

$524.00

Service Code	HCPCS 70210
Hospital Charge Code	1170432
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 Sinuses Paranasal < 3 Views - Report

Professional

Both

$65.00

Service Code	HCPCS 70210 26
Hospital Charge Code	630107
Hospital Revenue Code	972
Min. Negotiated Rate	$8.53
Max. Negotiated Rate	$55.25
Rate for Payer: AlohaCare Medicaid	$21.52
Rate for Payer: AlohaCare Medicare	$8.53
Rate for Payer: Cash Price	$42.25
Rate for Payer: Cash Price	$42.25
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	$36.70
Rate for Payer: Health Management Network Commercial	$55.25
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	$21.52
Rate for Payer: Ohana Health Plan Medicare	$8.53
Rate for Payer: UnitedHealthcare Medicaid	$21.52
Rate for Payer: UnitedHealthcare Medicare	$8.53

XR Sinuses Paranasal Complete

Facility

$536.00

Service Code	HCPCS 70220
Hospital Charge Code	1170434
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$519.92
Rate for Payer: AlohaCare Medicaid	$268.00
Rate for Payer: AlohaCare Medicare	$268.00
Rate for Payer: Cash Price	$348.40
Rate for Payer: Cash Price	$348.40
Rate for Payer: Devoted Health Medicare	$294.80
Rate for Payer: Hawaii Medical Service Association ABD	$25.96
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$268.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.19
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Humana Medicare	$268.00
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: Kaiser Permanente Medicaid	$273.36
Rate for Payer: Kaiser Permanente Medicare	$268.00
Rate for Payer: MDX Hawaii PPO	$519.92
Rate for Payer: Ohana Health Plan Medicaid	$268.00
Rate for Payer: Ohana Health Plan Medicare	$268.00
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: UnitedHealthcare Medicare	$268.00
Rate for Payer: University Health Alliance Commercial	$82.68

XR Sinuses Paranasal Complete

Facility

$536.00

Service Code	HCPCS 70220
Hospital Charge Code	1170434
Hospital Revenue Code	320
Min. Negotiated Rate	$455.60
Max. Negotiated Rate	$519.92
Rate for Payer: Cash Price	$348.40
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: MDX Hawaii PPO	$519.92

XR Sinuses Paranasal Complete - Report

Professional

Both

$88.00

Service Code	HCPCS 70220 26
Hospital Charge Code	630101
Hospital Revenue Code	972
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$74.80
Rate for Payer: AlohaCare Medicaid	$25.04
Rate for Payer: AlohaCare Medicare	$10.63
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Devoted Health Medicare	$11.69
Rate for Payer: Hawaii Medical Service Association Medicare	$10.63
Rate for Payer: Hawaii Western Management Group Commercial	$48.65
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$11.69
Rate for Payer: Kaiser Permanente Medicaid	$11.69
Rate for Payer: Kaiser Permanente Medicare	$11.69
Rate for Payer: Ohana Health Plan Medicaid	$25.04
Rate for Payer: Ohana Health Plan Medicare	$10.63
Rate for Payer: UnitedHealthcare Medicaid	$25.04
Rate for Payer: UnitedHealthcare Medicare	$10.63

XR Skull < 4 Views

Facility

$524.00

Service Code	HCPCS 70250
Hospital Charge Code	1170436
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 Skull < 4 Views

Facility

$524.00

Service Code	HCPCS 70250
Hospital Charge Code	1170436
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
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	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$262.00
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	$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	$20.40
Rate for Payer: UnitedHealthcare Medicare	$262.00
Rate for Payer: University Health Alliance Commercial	$72.65

XR Skull < 4 Views - Report

Professional

Both

$145.00

Service Code	HCPCS 70250 26
Hospital Charge Code	630097
Hospital Revenue Code	972
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$123.25
Rate for Payer: Devoted Health Medicare	$9.75
Rate for Payer: AlohaCare Medicaid	$24.01
Rate for Payer: AlohaCare Medicare	$8.86
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Medical Service Association Medicare	$8.86
Rate for Payer: Hawaii Western Management Group Commercial	$40.59
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$9.75
Rate for Payer: Kaiser Permanente Medicaid	$9.75
Rate for Payer: Kaiser Permanente Medicare	$9.75
Rate for Payer: Ohana Health Plan Medicaid	$24.01
Rate for Payer: Ohana Health Plan Medicare	$8.86
Rate for Payer: UnitedHealthcare Medicaid	$24.01
Rate for Payer: UnitedHealthcare Medicare	$8.86

XR Skull Complete

Facility

$625.00

Service Code	HCPCS 70260
Hospital Charge Code	1170438
Hospital Revenue Code	320
Min. Negotiated Rate	$531.25
Max. Negotiated Rate	$606.25
Rate for Payer: Cash Price	$406.25
Rate for Payer: Health Management Network Commercial	$531.25
Rate for Payer: Kaiser Permanente Commercial	$562.50
Rate for Payer: MDX Hawaii PPO	$606.25

XR Skull Complete

Facility

$625.00

Service Code	HCPCS 70260
Hospital Charge Code	1170438
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$606.25
Rate for Payer: AlohaCare Medicaid	$312.50
Rate for Payer: AlohaCare Medicare	$312.50
Rate for Payer: Cash Price	$406.25
Rate for Payer: Cash Price	$406.25
Rate for Payer: Devoted Health Medicare	$343.75
Rate for Payer: Hawaii Medical Service Association ABD	$29.64
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$312.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.30
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$531.25
Rate for Payer: Humana Medicare	$312.50
Rate for Payer: Kaiser Permanente Commercial	$562.50
Rate for Payer: Kaiser Permanente Medicaid	$318.75
Rate for Payer: Kaiser Permanente Medicare	$312.50
Rate for Payer: MDX Hawaii PPO	$606.25
Rate for Payer: Ohana Health Plan Medicaid	$312.50
Rate for Payer: Ohana Health Plan Medicare	$312.50
Rate for Payer: UnitedHealthcare Medicaid	$29.64
Rate for Payer: UnitedHealthcare Medicare	$312.50
Rate for Payer: University Health Alliance Commercial	$100.57

XR Skull Complete - Report

Professional

Both

$95.00

Service Code	HCPCS 70260 26
Hospital Charge Code	630093
Hospital Revenue Code	972
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$80.75
Rate for Payer: AlohaCare Medicaid	$29.68
Rate for Payer: AlohaCare Medicare	$13.39
Rate for Payer: Cash Price	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$14.73
Rate for Payer: Hawaii Medical Service Association Medicare	$13.39
Rate for Payer: Hawaii Western Management Group Commercial	$58.17
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$14.73
Rate for Payer: Kaiser Permanente Medicaid	$14.73
Rate for Payer: Kaiser Permanente Medicare	$14.73
Rate for Payer: Ohana Health Plan Medicaid	$29.68
Rate for Payer: Ohana Health Plan Medicare	$13.39
Rate for Payer: UnitedHealthcare Medicaid	$29.68
Rate for Payer: UnitedHealthcare Medicare	$13.39

XR Small Bowel w/ Multiple Series

Facility

$925.00

Service Code	HCPCS 74250
Hospital Charge Code	1170442
Hospital Revenue Code	320
Min. Negotiated Rate	$786.25
Max. Negotiated Rate	$897.25
Rate for Payer: Cash Price	$601.25
Rate for Payer: Health Management Network Commercial	$786.25
Rate for Payer: Kaiser Permanente Commercial	$832.50
Rate for Payer: MDX Hawaii PPO	$897.25

Know your out-of-pocket cost for care.

All Charges