Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Venography Extremity Left

Facility

$3,143.00

Service Code	HCPCS 75820 LT
Hospital Charge Code	8196611
Hospital Revenue Code	320
Min. Negotiated Rate	$2,671.55
Max. Negotiated Rate	$3,048.71
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: MDX Hawaii PPO	$3,048.71

XR Venography Extremity Right

Facility

$3,143.00

Service Code	HCPCS 75820 RT
Hospital Charge Code	8196614
Hospital Revenue Code	320
Min. Negotiated Rate	$31.51
Max. Negotiated Rate	$3,048.71
Rate for Payer: AlohaCare Medicaid	$1,571.50
Rate for Payer: AlohaCare Medicare	$1,571.50
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Devoted Health Medicare	$1,728.65
Rate for Payer: Hawaii Medical Service Association ABD	$31.51
Rate for Payer: Hawaii Medical Service Association Medicare	$1,571.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.37
Rate for Payer: Hawaii Western Management Group Commercial	$2,985.85
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Humana Medicare	$1,571.50
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: Kaiser Permanente Medicaid	$1,602.93
Rate for Payer: Kaiser Permanente Medicare	$1,571.50
Rate for Payer: MDX Hawaii PPO	$3,048.71
Rate for Payer: Ohana Health Plan Medicaid	$1,571.50
Rate for Payer: Ohana Health Plan Medicare	$1,571.50
Rate for Payer: UnitedHealthcare Medicaid	$31.51
Rate for Payer: UnitedHealthcare Medicare	$1,571.50
Rate for Payer: University Health Alliance Commercial	$215.77

XR Venography Extremity Right

Facility

$3,143.00

Service Code	HCPCS 75820 RT
Hospital Charge Code	8196614
Hospital Revenue Code	320
Min. Negotiated Rate	$2,671.55
Max. Negotiated Rate	$3,048.71
Rate for Payer: Cash Price	$2,042.95
Rate for Payer: Health Management Network Commercial	$2,671.55
Rate for Payer: Kaiser Permanente Commercial	$2,828.70
Rate for Payer: MDX Hawaii PPO	$3,048.71

XR Voiding Urethrocystography

Facility

$1,114.00

Service Code	HCPCS 74455
Hospital Charge Code	8221477
Hospital Revenue Code	320
Min. Negotiated Rate	$946.90
Max. Negotiated Rate	$1,080.58
Rate for Payer: Cash Price	$724.10
Rate for Payer: Health Management Network Commercial	$946.90
Rate for Payer: Kaiser Permanente Commercial	$1,002.60
Rate for Payer: MDX Hawaii PPO	$1,080.58

XR Voiding Urethrocystography

Facility

$1,114.00

Service Code	HCPCS 74455
Hospital Charge Code	8221477
Hospital Revenue Code	320
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$1,080.58
Rate for Payer: AlohaCare Medicaid	$557.00
Rate for Payer: AlohaCare Medicare	$557.00
Rate for Payer: Cash Price	$724.10
Rate for Payer: Cash Price	$724.10
Rate for Payer: Devoted Health Medicare	$612.70
Rate for Payer: Hawaii Medical Service Association ABD	$52.22
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$557.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$56.72
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$946.90
Rate for Payer: Humana Medicare	$557.00
Rate for Payer: Kaiser Permanente Commercial	$1,002.60
Rate for Payer: Kaiser Permanente Medicaid	$568.14
Rate for Payer: Kaiser Permanente Medicare	$557.00
Rate for Payer: MDX Hawaii PPO	$1,080.58
Rate for Payer: Ohana Health Plan Medicaid	$557.00
Rate for Payer: Ohana Health Plan Medicare	$557.00
Rate for Payer: UnitedHealthcare Medicaid	$52.22
Rate for Payer: UnitedHealthcare Medicare	$557.00
Rate for Payer: University Health Alliance Commercial	$182.02

XR Voiding Urethrocystography - Report

Professional

Both

$332.00

Service Code	HCPCS 74455 26
Hospital Charge Code	2444308
Hospital Revenue Code	972
Min. Negotiated Rate	$16.01
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$70.38
Rate for Payer: AlohaCare Medicare	$16.01
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$17.61
Rate for Payer: Hawaii Medical Service Association Medicare	$16.01
Rate for Payer: Hawaii Western Management Group Commercial	$87.58
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$17.61
Rate for Payer: Kaiser Permanente Medicaid	$17.61
Rate for Payer: Kaiser Permanente Medicare	$17.61
Rate for Payer: Ohana Health Plan Medicaid	$70.38
Rate for Payer: Ohana Health Plan Medicare	$16.01
Rate for Payer: UnitedHealthcare Medicaid	$70.38
Rate for Payer: UnitedHealthcare Medicare	$16.01

XR Wrist 2 Views Bilateral

Facility

$580.00

Service Code	HCPCS 73100 50
Hospital Charge Code	1170604
Hospital Revenue Code	320
Min. Negotiated Rate	$493.00
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60

XR Wrist 2 Views Bilateral

Facility

$580.00

Service Code	HCPCS 73100 50
Hospital Charge Code	1170604
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$551.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$57.07

XR Wrist 2 Views Bilateral - Report

Professional

Both

$70.00

Service Code	HCPCS 73100 26,50
Hospital Charge Code	613631
Hospital Revenue Code	972
Min. Negotiated Rate	$22.70
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$22.70
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$22.70
Rate for Payer: UnitedHealthcare Medicaid	$22.70

XR Wrist 2 Views Left

Facility

$580.00

Service Code	HCPCS 73100 LT
Hospital Charge Code	1170606
Hospital Revenue Code	320
Min. Negotiated Rate	$493.00
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60

XR Wrist 2 Views Left

Facility

$580.00

Service Code	HCPCS 73100 LT
Hospital Charge Code	1170606
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$551.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$57.07

XR Wrist 2 Views Left - Report

Professional

Both

$70.00

Service Code	HCPCS 73100 26,LT
Hospital Charge Code	613633
Hospital Revenue Code	972
Min. Negotiated Rate	$22.70
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$22.70
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$22.70
Rate for Payer: UnitedHealthcare Medicaid	$22.70

XR Wrist 2 Views Right

Facility

$580.00

Service Code	HCPCS 73100 RT
Hospital Charge Code	1170608
Hospital Revenue Code	320
Min. Negotiated Rate	$493.00
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60

XR Wrist 2 Views Right

Facility

$580.00

Service Code	HCPCS 73100 RT
Hospital Charge Code	1170608
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$551.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$57.07

XR Wrist 2 Views Right - Report

Professional

Both

$70.00

Service Code	HCPCS 73100 26,RT
Hospital Charge Code	613635
Hospital Revenue Code	972
Min. Negotiated Rate	$22.70
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$22.70
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$22.70
Rate for Payer: UnitedHealthcare Medicaid	$22.70

XR Wrist Complete 3+ Views Bilateral

Facility

$525.00

Service Code	HCPCS 73110 50
Hospital Charge Code	1170610
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 Wrist Complete 3+ Views Bilateral

Facility

$525.00

Service Code	HCPCS 73110 50
Hospital Charge Code	1170610
Hospital Revenue Code	320
Min. Negotiated Rate	$17.34
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	$17.34
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.95
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	$17.34
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$66.60

XR Wrist Complete 3+ Views Bilateral - Report

Professional

Both

$66.00

Service Code	HCPCS 73110 26,50
Hospital Charge Code	611599
Hospital Revenue Code	972
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$27.72
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Ohana Health Plan Medicaid	$27.72
Rate for Payer: UnitedHealthcare Medicaid	$27.72

XR Wrist Complete 3+ Views Left

Facility

$525.00

Service Code	HCPCS 73110 LT
Hospital Charge Code	1170612
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 Wrist Complete 3+ Views Left

Facility

$525.00

Service Code	HCPCS 73110 LT
Hospital Charge Code	1170612
Hospital Revenue Code	320
Min. Negotiated Rate	$17.34
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	$17.34
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.95
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	$17.34
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$66.60

XR Wrist Complete 3+ Views Left - Report

Professional

Both

$66.00

Service Code	HCPCS 73110 26,LT
Hospital Charge Code	611597
Hospital Revenue Code	972
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$27.72
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Ohana Health Plan Medicaid	$27.72
Rate for Payer: UnitedHealthcare Medicaid	$27.72

XR Wrist Complete 3+ Views Right

Facility

$525.00

Service Code	HCPCS 73110 RT
Hospital Charge Code	1170614
Hospital Revenue Code	320
Min. Negotiated Rate	$17.34
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	$17.34
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.95
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	$17.34
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$66.60

XR Wrist Complete 3+ Views Right

Facility

$525.00

Service Code	HCPCS 73110 RT
Hospital Charge Code	1170614
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 Wrist Complete 3+ Views Right - Report

Professional

Both

$66.00

Service Code	HCPCS 73110 26,RT
Hospital Charge Code	611595
Hospital Revenue Code	972
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$56.10
Rate for Payer: Cash Price	$42.90
Rate for Payer: AlohaCare Medicaid	$27.72
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$32.77
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Ohana Health Plan Medicaid	$27.72
Rate for Payer: UnitedHealthcare Medicaid	$27.72

Yes - OT Paraffin Bath Charge

Facility

$42.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	8372814
Hospital Revenue Code	430
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$21.00
Rate for Payer: AlohaCare Medicare	$21.00
Rate for Payer: Cash Price	$27.30
Rate for Payer: Cash Price	$27.30
Rate for Payer: Devoted Health Medicare	$23.10
Rate for Payer: Hawaii Medical Service Association Medicare	$21.00
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$21.00
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$21.00
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$21.00
Rate for Payer: Ohana Health Plan Medicare	$21.00
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$21.00
Rate for Payer: University Health Alliance Commercial	$30.61

Know your out-of-pocket cost for care.

All Charges