Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

77063 MG Mammo Implant Screening Bil w/ Tomo. Pro

Professional

Both

$43.00

Service Code	HCPCS 77063
Hospital Charge Code	11847075
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: AlohaCare Medicare	$54.85
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$60.34
Rate for Payer: Hawaii Medical Service Association Medicare	$54.85
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$60.34
Rate for Payer: Kaiser Permanente Medicaid	$60.34
Rate for Payer: Kaiser Permanente Medicare	$60.34
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: Ohana Health Plan Medicare	$54.85
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$54.85

77063 MG Mammo Implant Screening Bil w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063
Hospital Charge Code	11848520
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

77063 MG Mammo Implant Screening Bil w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063
Hospital Charge Code	11848520
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Implant Screening Lt w/ Tomo. Pro

Professional

Both

$43.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	11847076
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicaid	$33.66

77063 MG Mammo Implant Screening Lt w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	11858269
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Implant Screening Lt w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	11858269
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

77063 MG Mammo Implant Screening Rt w/ Tomo. Pro

Professional

Both

$43.00

Service Code	HCPCS 77063 52,RT
Hospital Charge Code	11847077
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicaid	$33.66

77063 MG Mammo Implant Screening Rt w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063 RT,52
Hospital Charge Code	11848521
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

77063 MG Mammo Implant Screening Rt w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063 RT,52
Hospital Charge Code	11848521
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Screening Bilateral w/ Tomo Pro

Professional

Both

$43.00

Service Code	HCPCS 77063
Hospital Charge Code	11858267
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: AlohaCare Medicare	$54.85
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$60.34
Rate for Payer: Hawaii Medical Service Association Medicare	$54.85
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$60.34
Rate for Payer: Kaiser Permanente Medicaid	$60.34
Rate for Payer: Kaiser Permanente Medicare	$60.34
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: Ohana Health Plan Medicare	$54.85
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$54.85

77063 MG Mammo Screening Bilateral w/ Tomo. Pro

Professional

Both

$43.00

Service Code	HCPCS 77063
Hospital Charge Code	12133854
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: AlohaCare Medicare	$54.85
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Devoted Health Medicare	$60.34
Rate for Payer: Hawaii Medical Service Association Medicare	$54.85
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$60.34
Rate for Payer: Kaiser Permanente Medicaid	$60.34
Rate for Payer: Kaiser Permanente Medicare	$60.34
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: Ohana Health Plan Medicare	$54.85
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$54.85

77063 MG Mammo Screening Bilateral w/ Tomo Tech

Facility

$75.00

Service Code	HCPCS 77063
Hospital Charge Code	11858266
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Screening Bilateral w/ Tomo Tech

Facility

$75.00

Service Code	HCPCS 77063
Hospital Charge Code	11858266
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

77063 MG Mammo Screening Bilateral w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063
Hospital Charge Code	12125583
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

77063 MG Mammo Screening Bilateral w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063
Hospital Charge Code	12125583
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Screening Left w/ Tomo Pro

Professional

Both

$43.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	11848519
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicaid	$33.66

77063 MG Mammo Screening Left w/ Tomo. Pro

Professional

Both

$43.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	12133855
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicaid	$33.66

77063 MG Mammo Screening Left w/ Tomo Tech

Facility

$75.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	11858268
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

77063 MG Mammo Screening Left w/ Tomo Tech

Facility

$75.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	11858268
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Screening Left w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	12125584
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Screening Left w/ Tomo. Tech

Facility

$75.00

Service Code	HCPCS 77063 52,LT
Hospital Charge Code	12125584
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

77063 MG Mammo Screening Right w/ Tomo Pro

Professional

Both

$43.00

Service Code	HCPCS 77063 52,RT
Hospital Charge Code	11847074
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicaid	$33.66

77063 MG Mammo Screening Right w/ Tomo. Pro

Professional

Both

$43.00

Service Code	HCPCS 77063 52,RT
Hospital Charge Code	12135848
Hospital Revenue Code	972
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$61.04
Rate for Payer: AlohaCare Medicaid	$33.66
Rate for Payer: Cash Price	$27.95
Rate for Payer: Cash Price	$27.95
Rate for Payer: Hawaii Western Management Group Commercial	$61.04
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Ohana Health Plan Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicaid	$33.66

77063 MG Mammo Screening Right w/ Tomo Tech

Facility

$75.00

Service Code	HCPCS 77063 52,RT
Hospital Charge Code	11847073
Hospital Revenue Code	403
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

77063 MG Mammo Screening Right w/ Tomo Tech

Facility

$75.00

Service Code	HCPCS 77063 52,RT
Hospital Charge Code	11847073
Hospital Revenue Code	403
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$113.48
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$37.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Devoted Health Medicare	$41.25
Rate for Payer: Hawaii Medical Service Association ABD	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$37.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.69
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$37.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$37.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$37.50
Rate for Payer: Ohana Health Plan Medicare	$37.50
Rate for Payer: UnitedHealthcare Medicaid	$33.66
Rate for Payer: UnitedHealthcare Medicare	$37.50
Rate for Payer: University Health Alliance Commercial	$113.48

Know your out-of-pocket cost for care.

All Charges