Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

77061 MG Mammo Diagnostic Right w/ Tomo. Tech

Facility

$351.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	12135853
Hospital Revenue Code	401
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77061 MG MAMMO DX TOMO UNILAT

Facility

$351.00

Service Code	HCPCS 77061
Hospital Charge Code	9929552
Hospital Revenue Code	320
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77061 MG MAMMO DX TOMO UNILAT

Professional

Both

$68.00

Service Code	HCPCS 77061
Hospital Charge Code	9929552
Hospital Revenue Code	972
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$206.71
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Hawaii Western Management Group Commercial	$206.71
Rate for Payer: Health Management Network Commercial	$57.80

77061 MG MAMMO DX TOMO UNILAT

Facility

$351.00

Service Code	HCPCS 77061
Hospital Charge Code	9929552
Hospital Revenue Code	320
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$340.47
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicare	$175.50

77061 MG Mammo Implant Diag Left w/ Tomo Pro

Professional

Both

$68.00

Service Code	HCPCS 77061 LT
Hospital Charge Code	11858272
Hospital Revenue Code	972
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$206.71
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Hawaii Western Management Group Commercial	$206.71
Rate for Payer: Health Management Network Commercial	$57.80

77061 MG Mammo Implant Diag Left w/ Tomo. Pro

Professional

Both

$68.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	12133858
Hospital Revenue Code	972
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$206.71
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Hawaii Western Management Group Commercial	$206.71
Rate for Payer: Health Management Network Commercial	$57.80

77061 MG Mammo Implant Diag Left w/ Tomo Tech

Facility

$351.00

Service Code	HCPCS 77061 LT
Hospital Charge Code	11858271
Hospital Revenue Code	401
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$340.47
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicare	$175.50

77061 MG Mammo Implant Diag Left w/ Tomo Tech

Facility

$351.00

Service Code	HCPCS 77061 LT
Hospital Charge Code	11858271
Hospital Revenue Code	401
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77061 MG Mammo Implant Diag Left w/ Tomo. Tech

Facility

$351.00

Service Code	HCPCS 77061 LT
Hospital Charge Code	12133857
Hospital Revenue Code	401
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77061 MG Mammo Implant Diag Left w/ Tomo. Tech

Facility

$351.00

Service Code	HCPCS 77061 LT
Hospital Charge Code	12133857
Hospital Revenue Code	401
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$340.47
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicare	$175.50

77061 MG Mammo Implant Diag Right w/ Tomo Pro

Professional

Both

$68.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	11848522
Hospital Revenue Code	972
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$206.71
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Hawaii Western Management Group Commercial	$206.71
Rate for Payer: Health Management Network Commercial	$57.80

77061 MG Mammo Implant Diag Right w/ Tomo. Pro

Professional

Both

$68.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	12135851
Hospital Revenue Code	972
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$206.71
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Hawaii Western Management Group Commercial	$206.71
Rate for Payer: Health Management Network Commercial	$57.80

77061 MG Mammo Implant Diag Right w/ Tomo Tech

Facility

$351.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	11858273
Hospital Revenue Code	401
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77061 MG Mammo Implant Diag Right w/ Tomo Tech

Facility

$351.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	11858273
Hospital Revenue Code	401
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$340.47
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicare	$175.50

77061 MG Mammo Implant Diag Right w/ Tomo. Tech

Facility

$351.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	12133859
Hospital Revenue Code	401
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$340.47
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicare	$175.50

77061 MG Mammo Implant Diag Right w/ Tomo. Tech

Facility

$351.00

Service Code	HCPCS 77061 RT
Hospital Charge Code	12133859
Hospital Revenue Code	401
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77062 MG Mammo Diagnostic Bilateral w/ Tomo Pro

Professional

Both

$88.00

Service Code	HCPCS 77062
Hospital Charge Code	11848524
Hospital Revenue Code	972
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$245.85
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Hawaii Western Management Group Commercial	$245.85
Rate for Payer: Health Management Network Commercial	$74.80

77062 MG Mammo Diagnostic Bilateral w/ Tomo. Pro

Professional

Both

$88.00

Service Code	HCPCS 77062
Hospital Charge Code	12135852
Hospital Revenue Code	972
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$245.85
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Hawaii Western Management Group Commercial	$245.85
Rate for Payer: Health Management Network Commercial	$74.80

77062 MG Mammo Diagnostic Bilateral w/ Tomo Tech

Facility

$351.00

Service Code	HCPCS 77062
Hospital Charge Code	11848523
Hospital Revenue Code	403
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$340.47
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicare	$175.50
Rate for Payer: University Health Alliance Commercial	$255.84

77062 MG Mammo Diagnostic Bilateral w/ Tomo Tech

Facility

$351.00

Service Code	HCPCS 77062
Hospital Charge Code	11848523
Hospital Revenue Code	403
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77062 MG Mammo Diagnostic Bilateral w/ Tomo. Tech

Facility

$351.00

Service Code	HCPCS 77062
Hospital Charge Code	12133860
Hospital Revenue Code	401
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

77062 MG Mammo Diagnostic Bilateral w/ Tomo. Tech

Facility

$351.00

Service Code	HCPCS 77062
Hospital Charge Code	12133860
Hospital Revenue Code	401
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$340.47
Rate for Payer: AlohaCare Medicaid	$175.50
Rate for Payer: AlohaCare Medicare	$175.50
Rate for Payer: Cash Price	$228.15
Rate for Payer: Devoted Health Medicare	$193.05
Rate for Payer: Hawaii Medical Service Association Medicare	$175.50
Rate for Payer: Hawaii Western Management Group Commercial	$333.45
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Humana Medicare	$175.50
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: Kaiser Permanente Medicaid	$179.01
Rate for Payer: Kaiser Permanente Medicare	$175.50
Rate for Payer: MDX Hawaii PPO	$340.47
Rate for Payer: Ohana Health Plan Medicaid	$175.50
Rate for Payer: Ohana Health Plan Medicare	$175.50
Rate for Payer: UnitedHealthcare Medicare	$175.50
Rate for Payer: University Health Alliance Commercial	$255.84

77062 MG Mammo Implant Diag Bilateral w/ Tomo. Pro

Professional

Both

$88.00

Service Code	HCPCS 77062
Hospital Charge Code	11858270
Hospital Revenue Code	972
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$245.85
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Hawaii Western Management Group Commercial	$245.85
Rate for Payer: Health Management Network Commercial	$74.80

77062 MG Mammo Implant Diag Bilateral w/ Tomo. Tech

Facility

$470.00

Service Code	HCPCS 77062
Hospital Charge Code	11847078
Hospital Revenue Code	401
Min. Negotiated Rate	$235.00
Max. Negotiated Rate	$455.90
Rate for Payer: AlohaCare Medicaid	$235.00
Rate for Payer: AlohaCare Medicare	$235.00
Rate for Payer: Cash Price	$305.50
Rate for Payer: Devoted Health Medicare	$258.50
Rate for Payer: Hawaii Medical Service Association Medicare	$235.00
Rate for Payer: Hawaii Western Management Group Commercial	$446.50
Rate for Payer: Health Management Network Commercial	$399.50
Rate for Payer: Humana Medicare	$235.00
Rate for Payer: Kaiser Permanente Commercial	$423.00
Rate for Payer: Kaiser Permanente Medicaid	$239.70
Rate for Payer: Kaiser Permanente Medicare	$235.00
Rate for Payer: MDX Hawaii PPO	$455.90
Rate for Payer: Ohana Health Plan Medicaid	$235.00
Rate for Payer: Ohana Health Plan Medicare	$235.00
Rate for Payer: UnitedHealthcare Medicare	$235.00
Rate for Payer: University Health Alliance Commercial	$342.58

77062 MG Mammo Implant Diag Bilateral w/ Tomo. Tech

Facility

$470.00

Service Code	HCPCS 77062
Hospital Charge Code	11847078
Hospital Revenue Code	401
Min. Negotiated Rate	$399.50
Max. Negotiated Rate	$455.90
Rate for Payer: Cash Price	$305.50
Rate for Payer: Health Management Network Commercial	$399.50
Rate for Payer: Kaiser Permanente Commercial	$423.00
Rate for Payer: MDX Hawaii PPO	$455.90

Know your out-of-pocket cost for care.

All Charges