Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Basic Metabolic Panel (BMP) FSI

Facility

$117.00

Service Code	HCPCS 80048
Hospital Charge Code	8117854
Hospital Revenue Code	301
Min. Negotiated Rate	$8.46
Max. Negotiated Rate	$113.49
Rate for Payer: AlohaCare Medicaid	$58.50
Rate for Payer: AlohaCare Medicare	$58.50
Rate for Payer: Cash Price	$76.05
Rate for Payer: Cash Price	$76.05
Rate for Payer: Devoted Health Medicare	$64.35
Rate for Payer: Hawaii Medical Service Association ABD	$11.70
Rate for Payer: Hawaii Medical Service Association Commercial	$10.57
Rate for Payer: Hawaii Medical Service Association Medicare	$58.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.29
Rate for Payer: Hawaii Western Management Group Commercial	$8.46
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Humana Medicare	$58.50
Rate for Payer: Kaiser Permanente Commercial	$105.30
Rate for Payer: Kaiser Permanente Medicaid	$59.67
Rate for Payer: Kaiser Permanente Medicare	$58.50
Rate for Payer: MDX Hawaii PPO	$113.49
Rate for Payer: Ohana Health Plan Medicaid	$58.50
Rate for Payer: Ohana Health Plan Medicare	$58.50
Rate for Payer: UnitedHealthcare Medicaid	$11.70
Rate for Payer: UnitedHealthcare Medicare	$58.50
Rate for Payer: University Health Alliance Commercial	$21.89

Basic Metabolic Panel POC

Facility

$104.00

Service Code	HCPCS 80047 RT,52
Hospital Charge Code	8419435
Hospital Revenue Code	301
Min. Negotiated Rate	$12.58
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association ABD	$30.51
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.58
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$30.51
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$56.44

Basic Metabolic Panel POC

Facility

$104.00

Service Code	HCPCS 80047 RT,52
Hospital Charge Code	8419435
Hospital Revenue Code	301
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

BB-TAK (AR-13226)

Facility

$133.00

Hospital Charge Code	12944036
Hospital Revenue Code	278
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$74.48

BB-TAK (AR-13226)

Facility

$133.00

Hospital Charge Code	12944036
Hospital Revenue Code	278
Min. Negotiated Rate	$74.48
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: University Health Alliance Commercial	$74.48

BB-TAK, NON-THREADED

Facility

$223.00

Hospital Charge Code	12974041
Hospital Revenue Code	272
Min. Negotiated Rate	$111.50
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$111.50
Rate for Payer: Cash Price	$144.95
Rate for Payer: Devoted Health Medicare	$122.65
Rate for Payer: Hawaii Medical Service Association Medicare	$111.50
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$111.50
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$111.50
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$111.50
Rate for Payer: Ohana Health Plan Medicare	$111.50
Rate for Payer: UnitedHealthcare Medicare	$111.50
Rate for Payer: University Health Alliance Commercial	$162.54

BB-TAK, NON-THREADED

Facility

$223.00

Hospital Charge Code	12974041
Hospital Revenue Code	272
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$144.95
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

BB-TAK, THREADED (AR-18800-11T)

Facility

$356.00

Hospital Charge Code	12971937
Hospital Revenue Code	272
Min. Negotiated Rate	$302.60
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$231.40
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: MDX Hawaii PPO	$345.32

BB-TAK, THREADED (AR-18800-11T)

Facility

$356.00

Hospital Charge Code	12971937
Hospital Revenue Code	272
Min. Negotiated Rate	$178.00
Max. Negotiated Rate	$345.32
Rate for Payer: AlohaCare Medicaid	$178.00
Rate for Payer: AlohaCare Medicare	$178.00
Rate for Payer: Cash Price	$231.40
Rate for Payer: Devoted Health Medicare	$195.80
Rate for Payer: Hawaii Medical Service Association Medicare	$178.00
Rate for Payer: Hawaii Western Management Group Commercial	$338.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Humana Medicare	$178.00
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: Kaiser Permanente Medicaid	$181.56
Rate for Payer: Kaiser Permanente Medicare	$178.00
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: Ohana Health Plan Medicaid	$178.00
Rate for Payer: Ohana Health Plan Medicare	$178.00
Rate for Payer: UnitedHealthcare Medicare	$178.00
Rate for Payer: University Health Alliance Commercial	$259.49

Bedside Thoracentesis

Facility

$1,402.00

Service Code	HCPCS 32554
Hospital Charge Code	9714821
Hospital Revenue Code	361
Min. Negotiated Rate	$1,191.70
Max. Negotiated Rate	$1,359.94
Rate for Payer: Cash Price	$911.30
Rate for Payer: Health Management Network Commercial	$1,191.70
Rate for Payer: Kaiser Permanente Commercial	$1,261.80
Rate for Payer: MDX Hawaii PPO	$1,359.94

Bedside Thoracentesis

Facility

$1,402.00

Service Code	HCPCS 32554
Hospital Charge Code	9714821
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$701.00
Rate for Payer: AlohaCare Medicare	$701.00
Rate for Payer: Cash Price	$911.30
Rate for Payer: Cash Price	$911.30
Rate for Payer: Devoted Health Medicare	$771.10
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	$701.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$1,191.70
Rate for Payer: Humana Medicare	$701.00
Rate for Payer: Kaiser Permanente Commercial	$1,261.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$701.00
Rate for Payer: MDX Hawaii PPO	$1,359.94
Rate for Payer: Ohana Health Plan Medicaid	$701.00
Rate for Payer: Ohana Health Plan Medicare	$701.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$701.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

BEHAVIORAL AND DEVELOPMENTAL DISORDERS

Facility

$15,195.62

Service Code	MSDRG 886
Min. Negotiated Rate	$15,195.62
Max. Negotiated Rate	$15,195.62
Rate for Payer: Hawaii Medical Service Association Commercial	$15,195.62

Behavioral, Qualitative Analysis Units

Facility

$657.00

Service Code	HCPCS 92524 GO,CO
Hospital Charge Code	2597756
Hospital Revenue Code	444
Min. Negotiated Rate	$558.45
Max. Negotiated Rate	$637.29
Rate for Payer: Cash Price	$427.05
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: MDX Hawaii PPO	$637.29

Behavioral, Qualitative Analysis Units

Facility

$657.00

Service Code	HCPCS 92524 GO,CO
Hospital Charge Code	2597756
Hospital Revenue Code	444
Min. Negotiated Rate	$114.94
Max. Negotiated Rate	$637.29
Rate for Payer: AlohaCare Medicaid	$328.50
Rate for Payer: AlohaCare Medicare	$328.50
Rate for Payer: Cash Price	$427.05
Rate for Payer: Cash Price	$427.05
Rate for Payer: Devoted Health Medicare	$361.35
Rate for Payer: Hawaii Medical Service Association Medicare	$328.50
Rate for Payer: Hawaii Western Management Group Commercial	$624.15
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Humana Medicare	$328.50
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: Kaiser Permanente Medicaid	$335.07
Rate for Payer: Kaiser Permanente Medicare	$328.50
Rate for Payer: MDX Hawaii PPO	$637.29
Rate for Payer: Ohana Health Plan Medicaid	$328.50
Rate for Payer: Ohana Health Plan Medicare	$328.50
Rate for Payer: UnitedHealthcare Medicaid	$114.94
Rate for Payer: UnitedHealthcare Medicare	$328.50
Rate for Payer: University Health Alliance Commercial	$478.89

Behav/Qual Analysis of Voice and Resonance Charge

Facility

$657.00

Service Code	HCPCS 92524 GO,CO
Hospital Charge Code	8171644
Hospital Revenue Code	444
Min. Negotiated Rate	$114.94
Max. Negotiated Rate	$637.29
Rate for Payer: AlohaCare Medicaid	$328.50
Rate for Payer: AlohaCare Medicare	$328.50
Rate for Payer: Cash Price	$427.05
Rate for Payer: Cash Price	$427.05
Rate for Payer: Devoted Health Medicare	$361.35
Rate for Payer: Hawaii Medical Service Association Medicare	$328.50
Rate for Payer: Hawaii Western Management Group Commercial	$624.15
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Humana Medicare	$328.50
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: Kaiser Permanente Medicaid	$335.07
Rate for Payer: Kaiser Permanente Medicare	$328.50
Rate for Payer: MDX Hawaii PPO	$637.29
Rate for Payer: Ohana Health Plan Medicaid	$328.50
Rate for Payer: Ohana Health Plan Medicare	$328.50
Rate for Payer: UnitedHealthcare Medicaid	$114.94
Rate for Payer: UnitedHealthcare Medicare	$328.50
Rate for Payer: University Health Alliance Commercial	$478.89

Behav/Qual Analysis of Voice and Resonance Charge

Facility

$657.00

Service Code	HCPCS 92524 GO,CO
Hospital Charge Code	8171644
Hospital Revenue Code	444
Min. Negotiated Rate	$558.45
Max. Negotiated Rate	$637.29
Rate for Payer: Cash Price	$427.05
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: MDX Hawaii PPO	$637.29

BENIGN PROSTATIC HYPERTROPHY WITH MCC

Facility

$26,898.28

Service Code	MSDRG 725
Min. Negotiated Rate	$26,898.28
Max. Negotiated Rate	$26,898.28
Rate for Payer: Hawaii Medical Service Association Commercial	$26,898.28

BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC

Facility

$26,898.28

Service Code	MSDRG 726
Min. Negotiated Rate	$26,898.28
Max. Negotiated Rate	$26,898.28
Rate for Payer: Hawaii Medical Service Association Commercial	$26,898.28

benzocaine-menthol 6 mg-10 mg lozenge [HHSC]

Facility

$3.00

Service Code	NDC 78112001266
Hospital Charge Code	2501094
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

benzocaine-menthol 6 mg-10 mg lozenge [HHSC]

Facility

$3.00

Service Code	NDC 78112001106
Hospital Charge Code	2501094
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

benzocaine-menthol 6 mg-10 mg lozenge [HHSC]

Facility

$3.00

Service Code	NDC 78112001106
Hospital Charge Code	2501094
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

benzocaine-menthol 6 mg-10 mg lozenge [HHSC]

Facility

$3.00

Service Code	NDC 78112001266
Hospital Charge Code	2501094
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

benzocaine-menthol 85gm spray [HHSC]

Facility

$40.41

Service Code	HCPCS A9270
Hospital Charge Code	2501049
Hospital Revenue Code	250
Min. Negotiated Rate	$34.35
Max. Negotiated Rate	$39.20
Rate for Payer: Cash Price	$26.27
Rate for Payer: Health Management Network Commercial	$34.35
Rate for Payer: Kaiser Permanente Commercial	$36.37
Rate for Payer: MDX Hawaii PPO	$39.20

benzocaine-menthol 85gm spray [HHSC]

Facility

$40.41

Service Code	HCPCS A9270
Hospital Charge Code	2501049
Hospital Revenue Code	637
Min. Negotiated Rate	$20.20
Max. Negotiated Rate	$39.20
Rate for Payer: AlohaCare Medicaid	$20.20
Rate for Payer: AlohaCare Medicare	$20.20
Rate for Payer: Cash Price	$26.27
Rate for Payer: Devoted Health Medicare	$22.23
Rate for Payer: Hawaii Medical Service Association Medicare	$20.20
Rate for Payer: Hawaii Western Management Group Commercial	$38.39
Rate for Payer: Health Management Network Commercial	$34.35
Rate for Payer: Humana Medicare	$20.20
Rate for Payer: Kaiser Permanente Commercial	$36.37
Rate for Payer: Kaiser Permanente Medicaid	$20.61
Rate for Payer: Kaiser Permanente Medicare	$20.20
Rate for Payer: MDX Hawaii PPO	$39.20
Rate for Payer: Ohana Health Plan Medicaid	$20.20
Rate for Payer: Ohana Health Plan Medicare	$20.20
Rate for Payer: UnitedHealthcare Medicare	$20.20
Rate for Payer: University Health Alliance Commercial	$29.45

Benzodiazepine, Urine Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8228840
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

Know your out-of-pocket cost for care.

All Charges