Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

E95706 EEG Tech - Intermittent Monitoring and Maintenance 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95706
Hospital Charge Code	12283600
Hospital Revenue Code	740
Min. Negotiated Rate	$1,683.85
Max. Negotiated Rate	$1,921.57
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: MDX Hawaii PPO	$1,921.57

E95707 EEG Tech - Continuous Real Time Monitoring and Maintenance 2 to 12 hours

Facility

$1,346.00

Service Code	HCPCS 95707
Hospital Charge Code	12284973
Hospital Revenue Code	740
Min. Negotiated Rate	$233.55
Max. Negotiated Rate	$1,305.62
Rate for Payer: AlohaCare Medicaid	$673.00
Rate for Payer: AlohaCare Medicare	$673.00
Rate for Payer: Cash Price	$874.90
Rate for Payer: Cash Price	$874.90
Rate for Payer: Devoted Health Medicare	$740.30
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$673.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,278.70
Rate for Payer: Health Management Network Commercial	$1,144.10
Rate for Payer: Humana Medicare	$673.00
Rate for Payer: Kaiser Permanente Commercial	$1,211.40
Rate for Payer: Kaiser Permanente Medicaid	$686.46
Rate for Payer: Kaiser Permanente Medicare	$673.00
Rate for Payer: MDX Hawaii PPO	$1,305.62
Rate for Payer: Ohana Health Plan Medicaid	$673.00
Rate for Payer: Ohana Health Plan Medicare	$673.00
Rate for Payer: UnitedHealthcare Medicaid	$233.55
Rate for Payer: UnitedHealthcare Medicare	$673.00
Rate for Payer: University Health Alliance Commercial	$981.10

E95707 EEG Tech - Continuous Real Time Monitoring and Maintenance 2 to 12 hours

Facility

$1,346.00

Service Code	HCPCS 95707
Hospital Charge Code	12284973
Hospital Revenue Code	740
Min. Negotiated Rate	$1,144.10
Max. Negotiated Rate	$1,305.62
Rate for Payer: Cash Price	$874.90
Rate for Payer: Health Management Network Commercial	$1,144.10
Rate for Payer: Kaiser Permanente Commercial	$1,211.40
Rate for Payer: MDX Hawaii PPO	$1,305.62

E95708 EEG Tech - Unmonitored 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95708
Hospital Charge Code	12273626
Hospital Revenue Code	740
Min. Negotiated Rate	$2,889.15
Max. Negotiated Rate	$3,297.03
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: MDX Hawaii PPO	$3,297.03

E95708 EEG Tech - Unmonitored 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95708
Hospital Charge Code	12273626
Hospital Revenue Code	740
Min. Negotiated Rate	$397.95
Max. Negotiated Rate	$3,297.03
Rate for Payer: AlohaCare Medicaid	$1,699.50
Rate for Payer: AlohaCare Medicare	$1,699.50
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Devoted Health Medicare	$1,869.45
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,699.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,229.05
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Humana Medicare	$1,699.50
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: Kaiser Permanente Medicaid	$1,733.49
Rate for Payer: Kaiser Permanente Medicare	$1,699.50
Rate for Payer: MDX Hawaii PPO	$3,297.03
Rate for Payer: Ohana Health Plan Medicaid	$1,699.50
Rate for Payer: Ohana Health Plan Medicare	$1,699.50
Rate for Payer: UnitedHealthcare Medicaid	$397.95
Rate for Payer: UnitedHealthcare Medicare	$1,699.50
Rate for Payer: University Health Alliance Commercial	$2,477.53

E95709 EEG Tech - Intermittent Monitoring and Maintenance 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95709
Hospital Charge Code	12284972
Hospital Revenue Code	740
Min. Negotiated Rate	$397.95
Max. Negotiated Rate	$3,297.03
Rate for Payer: AlohaCare Medicaid	$1,699.50
Rate for Payer: AlohaCare Medicare	$1,699.50
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Devoted Health Medicare	$1,869.45
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,699.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,229.05
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Humana Medicare	$1,699.50
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: Kaiser Permanente Medicaid	$1,733.49
Rate for Payer: Kaiser Permanente Medicare	$1,699.50
Rate for Payer: MDX Hawaii PPO	$3,297.03
Rate for Payer: Ohana Health Plan Medicaid	$1,699.50
Rate for Payer: Ohana Health Plan Medicare	$1,699.50
Rate for Payer: UnitedHealthcare Medicaid	$397.95
Rate for Payer: UnitedHealthcare Medicare	$1,699.50
Rate for Payer: University Health Alliance Commercial	$2,477.53

E95709 EEG Tech - Intermittent Monitoring and Maintenance 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95709
Hospital Charge Code	12284972
Hospital Revenue Code	740
Min. Negotiated Rate	$2,889.15
Max. Negotiated Rate	$3,297.03
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: MDX Hawaii PPO	$3,297.03

E95710 EEG Tech - Continuous Real Time Monitoring and Maintenance 12 to 26 hours each increment

Facility

$2,581.00

Service Code	HCPCS 95710
Hospital Charge Code	12273627
Hospital Revenue Code	740
Min. Negotiated Rate	$397.95
Max. Negotiated Rate	$2,503.57
Rate for Payer: AlohaCare Medicaid	$1,290.50
Rate for Payer: AlohaCare Medicare	$1,290.50
Rate for Payer: Cash Price	$1,677.65
Rate for Payer: Cash Price	$1,677.65
Rate for Payer: Devoted Health Medicare	$1,419.55
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,290.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,451.95
Rate for Payer: Health Management Network Commercial	$2,193.85
Rate for Payer: Humana Medicare	$1,290.50
Rate for Payer: Kaiser Permanente Commercial	$2,322.90
Rate for Payer: Kaiser Permanente Medicaid	$1,316.31
Rate for Payer: Kaiser Permanente Medicare	$1,290.50
Rate for Payer: MDX Hawaii PPO	$2,503.57
Rate for Payer: Ohana Health Plan Medicaid	$1,290.50
Rate for Payer: Ohana Health Plan Medicare	$1,290.50
Rate for Payer: UnitedHealthcare Medicaid	$397.95
Rate for Payer: UnitedHealthcare Medicare	$1,290.50
Rate for Payer: University Health Alliance Commercial	$1,881.29

E95710 EEG Tech - Continuous Real Time Monitoring and Maintenance 12 to 26 hours each increment

Facility

$2,581.00

Service Code	HCPCS 95710
Hospital Charge Code	12273627
Hospital Revenue Code	740
Min. Negotiated Rate	$2,193.85
Max. Negotiated Rate	$2,503.57
Rate for Payer: Cash Price	$1,677.65
Rate for Payer: Health Management Network Commercial	$2,193.85
Rate for Payer: Kaiser Permanente Commercial	$2,322.90
Rate for Payer: MDX Hawaii PPO	$2,503.57

E95812 EEG ñ Extended Monitoring ñ 41 to 60 Minutes

Facility

$1,575.00

Service Code	HCPCS 95812
Hospital Charge Code	12283595
Hospital Revenue Code	740
Min. Negotiated Rate	$92.69
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$92.69
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$181.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$92.69
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$1,148.02

E95812 EEG ñ Extended Monitoring ñ 41 to 60 Minutes

Professional

Both

$301.00

Service Code	HCPCS 95812
Hospital Charge Code	12283595
Hospital Revenue Code	986
Min. Negotiated Rate	$51.70
Max. Negotiated Rate	$471.87
Rate for Payer: AlohaCare Medicaid	$395.24
Rate for Payer: AlohaCare Medicare	$428.97
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$471.87
Rate for Payer: Hawaii Medical Service Association Medicare	$428.97
Rate for Payer: Hawaii Western Management Group Commercial	$51.70
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$471.87
Rate for Payer: Kaiser Permanente Medicaid	$471.87
Rate for Payer: Kaiser Permanente Medicare	$471.87
Rate for Payer: Ohana Health Plan Medicaid	$395.24
Rate for Payer: Ohana Health Plan Medicare	$428.97
Rate for Payer: UnitedHealthcare Medicaid	$395.24
Rate for Payer: UnitedHealthcare Medicare	$428.97

E95812 EEG ñ Extended Monitoring ñ 41 to 60 Minutes

Facility

$1,575.00

Service Code	HCPCS 95812
Hospital Charge Code	12283595
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95813 EEG ñ Extended Monitoring ñ 61 to 119 Minutes

Professional

Both

$301.00

Service Code	HCPCS 95813
Hospital Charge Code	12283596
Hospital Revenue Code	986
Min. Negotiated Rate	$107.72
Max. Negotiated Rate	$589.22
Rate for Payer: AlohaCare Medicaid	$498.26
Rate for Payer: AlohaCare Medicare	$535.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$589.22
Rate for Payer: Hawaii Medical Service Association Medicare	$535.65
Rate for Payer: Hawaii Western Management Group Commercial	$107.72
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$589.22
Rate for Payer: Kaiser Permanente Medicaid	$589.22
Rate for Payer: Kaiser Permanente Medicare	$589.22
Rate for Payer: Ohana Health Plan Medicaid	$498.26
Rate for Payer: Ohana Health Plan Medicare	$535.65
Rate for Payer: UnitedHealthcare Medicaid	$498.26
Rate for Payer: UnitedHealthcare Medicare	$535.65

E95813 EEG ñ Extended Monitoring ñ 61 to 119 Minutes

Facility

$1,575.00

Service Code	HCPCS 95813
Hospital Charge Code	12283596
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95813 EEG ñ Extended Monitoring ñ 61 to 119 Minutes

Facility

$1,575.00

Service Code	HCPCS 95813
Hospital Charge Code	12283596
Hospital Revenue Code	740
Min. Negotiated Rate	$111.39
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$111.39
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$111.39
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$1,148.02

E95816 EEG ñ Including Recording Awake and Drowsy

Facility

$1,537.00

Service Code	HCPCS 95816
Hospital Charge Code	12241748
Hospital Revenue Code	740
Min. Negotiated Rate	$1,306.45
Max. Negotiated Rate	$1,490.89
Rate for Payer: Cash Price	$999.05
Rate for Payer: Health Management Network Commercial	$1,306.45
Rate for Payer: Kaiser Permanente Commercial	$1,383.30
Rate for Payer: MDX Hawaii PPO	$1,490.89

E95816 EEG ñ Including Recording Awake and Drowsy

Professional

Both

$301.00

Service Code	HCPCS 95816
Hospital Charge Code	12241748
Hospital Revenue Code	986
Min. Negotiated Rate	$105.68
Max. Negotiated Rate	$509.83
Rate for Payer: AlohaCare Medicaid	$445.92
Rate for Payer: AlohaCare Medicare	$463.48
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$509.83
Rate for Payer: Hawaii Medical Service Association Medicare	$463.48
Rate for Payer: Hawaii Western Management Group Commercial	$105.68
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$509.83
Rate for Payer: Kaiser Permanente Medicaid	$509.83
Rate for Payer: Kaiser Permanente Medicare	$509.83
Rate for Payer: Ohana Health Plan Medicaid	$445.92
Rate for Payer: Ohana Health Plan Medicare	$463.48
Rate for Payer: UnitedHealthcare Medicaid	$445.92
Rate for Payer: UnitedHealthcare Medicare	$463.48

E95816 EEG ñ Including Recording Awake and Drowsy

Facility

$1,537.00

Service Code	HCPCS 95816
Hospital Charge Code	12241748
Hospital Revenue Code	740
Min. Negotiated Rate	$84.17
Max. Negotiated Rate	$1,490.89
Rate for Payer: AlohaCare Medicaid	$768.50
Rate for Payer: AlohaCare Medicare	$768.50
Rate for Payer: Cash Price	$999.05
Rate for Payer: Cash Price	$999.05
Rate for Payer: Devoted Health Medicare	$845.35
Rate for Payer: Hawaii Medical Service Association ABD	$84.17
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$768.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$145.63
Rate for Payer: Hawaii Western Management Group Commercial	$1,460.15
Rate for Payer: Health Management Network Commercial	$1,306.45
Rate for Payer: Humana Medicare	$768.50
Rate for Payer: Kaiser Permanente Commercial	$1,383.30
Rate for Payer: Kaiser Permanente Medicaid	$783.87
Rate for Payer: Kaiser Permanente Medicare	$768.50
Rate for Payer: MDX Hawaii PPO	$1,490.89
Rate for Payer: Ohana Health Plan Medicaid	$768.50
Rate for Payer: Ohana Health Plan Medicare	$768.50
Rate for Payer: UnitedHealthcare Medicaid	$84.17
Rate for Payer: UnitedHealthcare Medicare	$768.50
Rate for Payer: University Health Alliance Commercial	$1,120.32

E95819 EEG ñ Including Recording Awake and Asleep

Professional

Both

$301.00

Service Code	HCPCS 95819
Hospital Charge Code	12283597
Hospital Revenue Code	986
Min. Negotiated Rate	$114.84
Max. Negotiated Rate	$595.68
Rate for Payer: AlohaCare Medicaid	$514.57
Rate for Payer: AlohaCare Medicare	$541.53
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$595.68
Rate for Payer: Hawaii Medical Service Association Medicare	$541.53
Rate for Payer: Hawaii Western Management Group Commercial	$114.84
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$595.68
Rate for Payer: Kaiser Permanente Medicaid	$595.68
Rate for Payer: Kaiser Permanente Medicare	$595.68
Rate for Payer: Ohana Health Plan Medicaid	$514.57
Rate for Payer: Ohana Health Plan Medicare	$541.53
Rate for Payer: UnitedHealthcare Medicaid	$514.57
Rate for Payer: UnitedHealthcare Medicare	$541.53

E95819 EEG ñ Including Recording Awake and Asleep

Facility

$1,575.00

Service Code	HCPCS 95819
Hospital Charge Code	12283597
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95819 EEG ñ Including Recording Awake and Asleep

Facility

$1,575.00

Service Code	HCPCS 95819
Hospital Charge Code	12283597
Hospital Revenue Code	740
Min. Negotiated Rate	$65.74
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$65.74
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$174.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$65.74
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$1,148.02

E95822 EEG ñ Recording in Coma of Sleep ONLY

Facility

$1,575.00

Service Code	HCPCS 95822
Hospital Charge Code	12283598
Hospital Revenue Code	740
Min. Negotiated Rate	$107.20
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$107.20
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$169.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$107.20
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$1,148.02

E95822 EEG ñ Recording in Coma of Sleep ONLY

Facility

$1,575.00

Service Code	HCPCS 95822
Hospital Charge Code	12283598
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95822 EEG ñ Recording in Coma of Sleep ONLY

Professional

Both

$301.00

Service Code	HCPCS 95822
Hospital Charge Code	12283598
Hospital Revenue Code	986
Min. Negotiated Rate	$103.56
Max. Negotiated Rate	$551.61
Rate for Payer: AlohaCare Medicaid	$466.95
Rate for Payer: AlohaCare Medicare	$501.46
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$551.61
Rate for Payer: Hawaii Medical Service Association Medicare	$501.46
Rate for Payer: Hawaii Western Management Group Commercial	$103.56
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$551.61
Rate for Payer: Kaiser Permanente Medicaid	$551.61
Rate for Payer: Kaiser Permanente Medicare	$551.61
Rate for Payer: Ohana Health Plan Medicaid	$466.95
Rate for Payer: Ohana Health Plan Medicare	$501.46
Rate for Payer: UnitedHealthcare Medicaid	$466.95
Rate for Payer: UnitedHealthcare Medicare	$501.46

E95824 EEG ñ Cerebral Death Evaluation ONLY

Facility

$2,151.00

Service Code	HCPCS 95824
Hospital Charge Code	12283599
Hospital Revenue Code	740
Min. Negotiated Rate	$1,828.35
Max. Negotiated Rate	$2,086.47
Rate for Payer: Cash Price	$1,398.15
Rate for Payer: Health Management Network Commercial	$1,828.35
Rate for Payer: Kaiser Permanente Commercial	$1,935.90
Rate for Payer: MDX Hawaii PPO	$2,086.47

Know your out-of-pocket cost for care.

All Charges