Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

0042T CT BRAIN PERFUSION

Facility

$1,321.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060832
Hospital Revenue Code	975
Min. Negotiated Rate	$660.50
Max. Negotiated Rate	$1,281.37
Rate for Payer: AlohaCare Medicaid	$660.50
Rate for Payer: AlohaCare Medicare	$660.50
Rate for Payer: Cash Price	$858.65
Rate for Payer: Devoted Health Medicare	$726.55
Rate for Payer: Hawaii Medical Service Association Medicare	$660.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,254.95
Rate for Payer: Health Management Network Commercial	$1,122.85
Rate for Payer: Humana Medicare	$660.50
Rate for Payer: Kaiser Permanente Commercial	$1,188.90
Rate for Payer: Kaiser Permanente Medicaid	$673.71
Rate for Payer: Kaiser Permanente Medicare	$660.50
Rate for Payer: MDX Hawaii PPO	$1,281.37
Rate for Payer: Ohana Health Plan Medicaid	$660.50
Rate for Payer: Ohana Health Plan Medicare	$660.50
Rate for Payer: UnitedHealthcare Medicare	$660.50
Rate for Payer: University Health Alliance Commercial	$962.88

0042T CT BRAIN PERFUSION

Facility

$1,321.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060832
Hospital Revenue Code	975
Min. Negotiated Rate	$1,122.85
Max. Negotiated Rate	$1,281.37
Rate for Payer: Cash Price	$858.65
Rate for Payer: Health Management Network Commercial	$1,122.85
Rate for Payer: Kaiser Permanente Commercial	$1,188.90
Rate for Payer: MDX Hawaii PPO	$1,281.37

0042T CT BRAIN PERFUSION - DO NOT USE

Facility

$1,554.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060831
Hospital Revenue Code	975
Min. Negotiated Rate	$777.00
Max. Negotiated Rate	$1,507.38
Rate for Payer: AlohaCare Medicaid	$777.00
Rate for Payer: AlohaCare Medicare	$777.00
Rate for Payer: Cash Price	$1,010.10
Rate for Payer: Devoted Health Medicare	$854.70
Rate for Payer: Hawaii Medical Service Association Medicare	$777.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,476.30
Rate for Payer: Health Management Network Commercial	$1,320.90
Rate for Payer: Humana Medicare	$777.00
Rate for Payer: Kaiser Permanente Commercial	$1,398.60
Rate for Payer: Kaiser Permanente Medicaid	$792.54
Rate for Payer: Kaiser Permanente Medicare	$777.00
Rate for Payer: MDX Hawaii PPO	$1,507.38
Rate for Payer: Ohana Health Plan Medicaid	$777.00
Rate for Payer: Ohana Health Plan Medicare	$777.00
Rate for Payer: UnitedHealthcare Medicare	$777.00
Rate for Payer: University Health Alliance Commercial	$1,132.71

0042T CT BRAIN PERFUSION - DO NOT USE

Facility

$1,554.00

Service Code	HCPCS 0042T
Hospital Charge Code	10060831
Hospital Revenue Code	975
Min. Negotiated Rate	$1,320.90
Max. Negotiated Rate	$1,507.38
Rate for Payer: Cash Price	$1,010.10
Rate for Payer: Health Management Network Commercial	$1,320.90
Rate for Payer: Kaiser Permanente Commercial	$1,398.60
Rate for Payer: MDX Hawaii PPO	$1,507.38

0081A Pfizer Pediatric First Dose

Facility

$134.00

Service Code	HCPCS 0171A
Hospital Charge Code	10656900
Hospital Revenue Code	771
Min. Negotiated Rate	$67.00
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$97.67

0081A Pfizer Pediatric First Dose

Facility

$134.00

Service Code	HCPCS 0171A
Hospital Charge Code	10656900
Hospital Revenue Code	771
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

0082A Pfizer Pediatric Second Dose

Facility

$134.00

Service Code	HCPCS 0172A
Hospital Charge Code	10655402
Hospital Revenue Code	771
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

0082A Pfizer Pediatric Second Dose

Facility

$134.00

Service Code	HCPCS 0172A
Hospital Charge Code	10655402
Hospital Revenue Code	771
Min. Negotiated Rate	$67.00
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$97.67

00840 LAPOROSCOPY LOWER ENDOSCOPY ANES PRO FEE

Professional

Both

$191.00

Hospital Charge Code	8759950
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

01200 Anesthesia for all closed procedures involving hip joint

Professional

Both

$191.00

Hospital Charge Code	13073793
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

01210-OPN PROC HIP JOINT. ProFee

Professional

Both

$210.00

Hospital Charge Code	11251411
Hospital Revenue Code	975
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$178.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Health Management Network Commercial	$178.50

01940 Anesthesia for percutaneous image guided destruction procedures by neurolytic agent on the spi

Professional

Both

$41.00

Hospital Charge Code	9901578
Hospital Revenue Code	963
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$34.85
Rate for Payer: Cash Price	$26.65
Rate for Payer: Health Management Network Commercial	$34.85

01942 Anesthesia for percutaneos image guilded neuromodulation or intravertebral procedures(eg, kyph

Professional

Both

$191.00

Hospital Charge Code	9901580
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

10005 Fine needle aspiration biopsy, including ultrasound guidance; first lesion

Professional

Both

$986.00

Service Code	HCPCS 10005
Hospital Charge Code	8741040
Hospital Revenue Code	972
Min. Negotiated Rate	$61.35
Max. Negotiated Rate	$838.10
Rate for Payer: AlohaCare Medicaid	$72.24
Rate for Payer: AlohaCare Medicare	$61.35
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Devoted Health Medicare	$67.48
Rate for Payer: Hawaii Medical Service Association ABD	$72.24
Rate for Payer: Hawaii Medical Service Association Commercial	$123.13
Rate for Payer: Hawaii Medical Service Association Medicare	$61.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$72.24
Rate for Payer: Hawaii Western Management Group Commercial	$137.80
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$67.48
Rate for Payer: Kaiser Permanente Medicaid	$67.48
Rate for Payer: Kaiser Permanente Medicare	$67.48
Rate for Payer: Ohana Health Plan Medicaid	$72.24
Rate for Payer: Ohana Health Plan Medicare	$61.35
Rate for Payer: UnitedHealthcare Medicaid	$72.24
Rate for Payer: UnitedHealthcare Medicare	$61.35
Rate for Payer: University Health Alliance Commercial	$78.33

10009 FINE NDL ASPIRATION BX W/CT GDN 1ST LSN CHARGE

Professional

Both

$986.00

Service Code	HCPCS 10009
Hospital Charge Code	8668994
Hospital Revenue Code	975
Min. Negotiated Rate	$91.60
Max. Negotiated Rate	$838.10
Rate for Payer: AlohaCare Medicaid	$106.88
Rate for Payer: AlohaCare Medicare	$91.60
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Devoted Health Medicare	$100.76
Rate for Payer: Hawaii Medical Service Association ABD	$106.88
Rate for Payer: Hawaii Medical Service Association Commercial	$184.78
Rate for Payer: Hawaii Medical Service Association Medicare	$91.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$106.88
Rate for Payer: Hawaii Western Management Group Commercial	$530.92
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$100.76
Rate for Payer: Kaiser Permanente Medicaid	$100.76
Rate for Payer: Kaiser Permanente Medicare	$100.76
Rate for Payer: Ohana Health Plan Medicaid	$106.88
Rate for Payer: Ohana Health Plan Medicare	$91.60
Rate for Payer: UnitedHealthcare Medicaid	$106.88
Rate for Payer: UnitedHealthcare Medicare	$91.60
Rate for Payer: University Health Alliance Commercial	$115.70

10021-Aspiration Fine Needle w/o Imaging

Facility

$810.00

Service Code	HCPCS 10021
Hospital Charge Code	8080041
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$405.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Devoted Health Medicare	$445.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$405.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$769.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Humana Medicare	$405.00
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$405.00
Rate for Payer: MDX Hawaii PPO	$785.70
Rate for Payer: Ohana Health Plan Medicaid	$405.00
Rate for Payer: Ohana Health Plan Medicare	$405.00
Rate for Payer: UnitedHealthcare Medicare	$405.00
Rate for Payer: University Health Alliance Commercial	$590.41

10021-Aspiration Fine Needle w/o Imaging

Facility

$810.00

Service Code	HCPCS 10021
Hospital Charge Code	8080041
Hospital Revenue Code	450
Min. Negotiated Rate	$688.50
Max. Negotiated Rate	$785.70
Rate for Payer: Cash Price	$526.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: MDX Hawaii PPO	$785.70

10021 FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE TechFee

Facility

$880.00

Service Code	HCPCS 10021
Hospital Charge Code	8022536
Hospital Revenue Code	450
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

10021 FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE TechFee

Facility

$880.00

Service Code	HCPCS 10021
Hospital Charge Code	8022536
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$641.43

10022 CT GUIDED FNA

Facility

$770.00

Service Code	HCPCS 10022
Hospital Charge Code	10060853
Hospital Revenue Code	361
Min. Negotiated Rate	$654.50
Max. Negotiated Rate	$746.90
Rate for Payer: Cash Price	$500.50
Rate for Payer: Health Management Network Commercial	$654.50
Rate for Payer: Kaiser Permanente Commercial	$693.00
Rate for Payer: MDX Hawaii PPO	$746.90

10022 CT GUIDED FNA

Facility

$770.00

Service Code	HCPCS 10022
Hospital Charge Code	10060853
Hospital Revenue Code	361
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$385.00
Rate for Payer: AlohaCare Medicare	$385.00
Rate for Payer: Cash Price	$500.50
Rate for Payer: Cash Price	$500.50
Rate for Payer: Devoted Health Medicare	$423.50
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$385.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$654.50
Rate for Payer: Humana Medicare	$385.00
Rate for Payer: Kaiser Permanente Commercial	$693.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$385.00
Rate for Payer: MDX Hawaii PPO	$746.90
Rate for Payer: Ohana Health Plan Medicaid	$385.00
Rate for Payer: Ohana Health Plan Medicare	$385.00
Rate for Payer: UnitedHealthcare Medicare	$385.00
Rate for Payer: University Health Alliance Commercial	$561.25

10022 FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE ProFee

Professional

Both

$315.00

Service Code	HCPCS 10022
Hospital Charge Code	8016361
Hospital Revenue Code	972
Min. Negotiated Rate	$86.58
Max. Negotiated Rate	$267.75
Rate for Payer: Cash Price	$204.75
Rate for Payer: Cash Price	$204.75
Rate for Payer: Hawaii Western Management Group Commercial	$86.58
Rate for Payer: Health Management Network Commercial	$267.75

10030 Image Guided Catheter Fluir Collection Drainage

Facility

$2,322.00

Service Code	HCPCS 10030
Hospital Charge Code	8037063
Hospital Revenue Code	361
Min. Negotiated Rate	$1,973.70
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: MDX Hawaii PPO	$2,252.34

10030 Image Guided Catheter Fluir Collection Drainage

Facility

$2,322.00

Service Code	HCPCS 10030
Hospital Charge Code	8037063
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,161.00
Rate for Payer: AlohaCare Medicare	$1,161.00
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Cash Price	$1,509.30
Rate for Payer: Devoted Health Medicare	$1,277.10
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,161.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Humana Medicare	$1,161.00
Rate for Payer: Kaiser Permanente Commercial	$2,089.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,161.00
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: Ohana Health Plan Medicaid	$1,161.00
Rate for Payer: Ohana Health Plan Medicare	$1,161.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,161.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

10030 IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYM ProFee

Professional

Both

$986.00

Service Code	HCPCS 10030
Hospital Charge Code	8016362
Hospital Revenue Code	972
Min. Negotiated Rate	$115.65
Max. Negotiated Rate	$893.88
Rate for Payer: AlohaCare Medicaid	$132.13
Rate for Payer: AlohaCare Medicare	$115.65
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Devoted Health Medicare	$127.22
Rate for Payer: Hawaii Medical Service Association ABD	$132.13
Rate for Payer: Hawaii Medical Service Association Commercial	$243.58
Rate for Payer: Hawaii Medical Service Association Medicare	$115.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.13
Rate for Payer: Hawaii Western Management Group Commercial	$893.88
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$127.22
Rate for Payer: Kaiser Permanente Medicaid	$127.22
Rate for Payer: Kaiser Permanente Medicare	$127.22
Rate for Payer: Ohana Health Plan Medicaid	$132.13
Rate for Payer: Ohana Health Plan Medicare	$115.65
Rate for Payer: UnitedHealthcare Medicaid	$132.13
Rate for Payer: UnitedHealthcare Medicare	$115.65
Rate for Payer: University Health Alliance Commercial	$160.00

Know your out-of-pocket cost for care.

All Charges