Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$14.68
Max. Negotiated Rate	$2,086.47
Rate for Payer: AlohaCare Medicaid	$1,075.50
Rate for Payer: AlohaCare Medicare	$1,075.50
Rate for Payer: Cash Price	$1,398.15
Rate for Payer: Cash Price	$1,398.15
Rate for Payer: Devoted Health Medicare	$1,183.05
Rate for Payer: Hawaii Medical Service Association ABD	$43.18
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,075.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.68
Rate for Payer: Hawaii Western Management Group Commercial	$2,043.45
Rate for Payer: Health Management Network Commercial	$1,828.35
Rate for Payer: Humana Medicare	$1,075.50
Rate for Payer: Kaiser Permanente Commercial	$1,935.90
Rate for Payer: Kaiser Permanente Medicaid	$1,097.01
Rate for Payer: Kaiser Permanente Medicare	$1,075.50
Rate for Payer: MDX Hawaii PPO	$2,086.47
Rate for Payer: Ohana Health Plan Medicaid	$1,075.50
Rate for Payer: Ohana Health Plan Medicare	$1,075.50
Rate for Payer: UnitedHealthcare Medicaid	$43.18
Rate for Payer: UnitedHealthcare Medicare	$1,075.50
Rate for Payer: University Health Alliance Commercial	$1,567.86

E95824 EEG ñ Cerebral Death Evaluation ONLY

Professional

Both

$519.00

Service Code	HCPCS 95824
Hospital Charge Code	12283599
Hospital Revenue Code	986
Min. Negotiated Rate	$43.18
Max. Negotiated Rate	$441.15
Rate for Payer: AlohaCare Medicaid	$43.18
Rate for Payer: Cash Price	$337.35
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$49.16
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Ohana Health Plan Medicaid	$43.18
Rate for Payer: UnitedHealthcare Medicaid	$43.18

Each Additional 90472 - Admin Immunization charge

Facility

$142.00

Service Code	HCPCS 90472
Hospital Charge Code	12139186
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.28
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$103.50

Each Additional 90472 - Admin Immunization charge

Facility

$142.00

Service Code	HCPCS 90472
Hospital Charge Code	12139186
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Ear Irrigation/ Lavage POC

Facility

$48.00

Service Code	HCPCS 69209
Hospital Charge Code	8196912
Hospital Revenue Code	521
Min. Negotiated Rate	$18.16
Max. Negotiated Rate	$75.34
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$24.00
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Devoted Health Medicare	$26.40
Rate for Payer: Hawaii Medical Service Association Commercial	$75.34
Rate for Payer: Hawaii Medical Service Association Medicare	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$24.00
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$24.00
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$24.00
Rate for Payer: Ohana Health Plan Medicare	$24.00
Rate for Payer: UnitedHealthcare Medicaid	$18.16
Rate for Payer: UnitedHealthcare Medicare	$24.00
Rate for Payer: University Health Alliance Commercial	$34.99

Ear Irrigation/ Lavage POC

Facility

$48.00

Service Code	HCPCS 69209
Hospital Charge Code	8196912
Hospital Revenue Code	521
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$31.20
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$38,040.03

Service Code	MSDRG 147
Min. Negotiated Rate	$38,040.03
Max. Negotiated Rate	$38,040.03
Rate for Payer: Hawaii Medical Service Association Commercial	$38,040.03

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$38,040.03

Service Code	MSDRG 146
Min. Negotiated Rate	$38,040.03
Max. Negotiated Rate	$38,040.03
Rate for Payer: Hawaii Medical Service Association Commercial	$38,040.03

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$38,040.03

Service Code	MSDRG 148
Min. Negotiated Rate	$38,040.03
Max. Negotiated Rate	$38,040.03
Rate for Payer: Hawaii Medical Service Association Commercial	$38,040.03

EBV Epstein Barr Virus Capsid Antigen, IgG, IgM FSI

Facility

$101.00

Service Code	HCPCS 86665
Hospital Charge Code	8117903
Hospital Revenue Code	302
Min. Negotiated Rate	$18.14
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association ABD	$25.07
Rate for Payer: Hawaii Medical Service Association Commercial	$22.68
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.32
Rate for Payer: Hawaii Western Management Group Commercial	$18.14
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$25.07
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$46.90

EBV Epstein Barr Virus Capsid Antigen, IgG, IgM FSI

Facility

$101.00

Service Code	HCPCS 86665
Hospital Charge Code	8117903
Hospital Revenue Code	302
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

ECHO DOPPLER COLOR FLOW CHARGE

Facility

$3,040.00

Service Code	HCPCS 93306
Hospital Charge Code	8495487
Hospital Revenue Code	483
Min. Negotiated Rate	$132.88
Max. Negotiated Rate	$2,948.80
Rate for Payer: AlohaCare Medicaid	$1,520.00
Rate for Payer: AlohaCare Medicare	$1,520.00
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Devoted Health Medicare	$1,672.00
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	$1,520.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$2,888.00
Rate for Payer: Health Management Network Commercial	$2,584.00
Rate for Payer: Humana Medicare	$1,520.00
Rate for Payer: Kaiser Permanente Commercial	$2,736.00
Rate for Payer: Kaiser Permanente Medicaid	$1,550.40
Rate for Payer: Kaiser Permanente Medicare	$1,520.00
Rate for Payer: MDX Hawaii PPO	$2,948.80
Rate for Payer: Ohana Health Plan Medicaid	$1,520.00
Rate for Payer: Ohana Health Plan Medicare	$1,520.00
Rate for Payer: UnitedHealthcare Medicaid	$132.88
Rate for Payer: UnitedHealthcare Medicare	$1,520.00
Rate for Payer: University Health Alliance Commercial	$2,215.86

ECHO DOPPLER COLOR FLOW CHARGE

Facility

$3,040.00

Service Code	HCPCS 93306
Hospital Charge Code	8495487
Hospital Revenue Code	483
Min. Negotiated Rate	$2,584.00
Max. Negotiated Rate	$2,948.80
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Health Management Network Commercial	$2,584.00
Rate for Payer: Kaiser Permanente Commercial	$2,736.00
Rate for Payer: MDX Hawaii PPO	$2,948.80

Echovirus Panel, CSF FSI

Facility

$101.00

Service Code	HCPCS 86658
Hospital Charge Code	8228865
Hospital Revenue Code	302
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association ABD	$10.92
Rate for Payer: Hawaii Medical Service Association Commercial	$16.29
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.99
Rate for Payer: Hawaii Western Management Group Commercial	$13.03
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$10.92
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$33.67

Echovirus Panel, CSF FSI

Facility

$101.00

Service Code	HCPCS 86658
Hospital Charge Code	8228865
Hospital Revenue Code	302
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES

Facility

$502,118.22

Service Code	MSDRG 003
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$502,118.22
Rate for Payer: Hawaii Medical Service Association Commercial	$502,118.22
Rate for Payer: University Health Alliance Commercial	$10,400.00

EKG POC - Nursing

Facility

$370.00

Service Code	HCPCS 93005
Hospital Charge Code	8228954
Hospital Revenue Code	730
Min. Negotiated Rate	$15.16
Max. Negotiated Rate	$358.90
Rate for Payer: AlohaCare Medicaid	$185.00
Rate for Payer: AlohaCare Medicare	$185.00
Rate for Payer: Cash Price	$240.50
Rate for Payer: Cash Price	$240.50
Rate for Payer: Devoted Health Medicare	$203.50
Rate for Payer: Hawaii Medical Service Association Commercial	$75.34
Rate for Payer: Hawaii Medical Service Association Medicare	$185.00
Rate for Payer: Hawaii Western Management Group Commercial	$351.50
Rate for Payer: Health Management Network Commercial	$314.50
Rate for Payer: Humana Medicare	$185.00
Rate for Payer: Kaiser Permanente Commercial	$333.00
Rate for Payer: Kaiser Permanente Medicaid	$188.70
Rate for Payer: Kaiser Permanente Medicare	$185.00
Rate for Payer: MDX Hawaii PPO	$358.90
Rate for Payer: Ohana Health Plan Medicaid	$185.00
Rate for Payer: Ohana Health Plan Medicare	$185.00
Rate for Payer: UnitedHealthcare Medicaid	$15.16
Rate for Payer: UnitedHealthcare Medicare	$185.00
Rate for Payer: University Health Alliance Commercial	$269.69

EKG POC - Nursing

Facility

$370.00

Service Code	HCPCS 93005
Hospital Charge Code	8228954
Hospital Revenue Code	730
Min. Negotiated Rate	$314.50
Max. Negotiated Rate	$358.90
Rate for Payer: Cash Price	$240.50
Rate for Payer: Health Management Network Commercial	$314.50
Rate for Payer: Kaiser Permanente Commercial	$333.00
Rate for Payer: MDX Hawaii PPO	$358.90

Elbow Orthosis, rigid, w/o joint, prefab, OTS (counterforce)

Facility

$143.00

Service Code	HCPCS L3762
Hospital Charge Code	13381786
Hospital Revenue Code	274
Min. Negotiated Rate	$80.08
Max. Negotiated Rate	$138.71
Rate for Payer: Cash Price	$92.95
Rate for Payer: Hawaii Western Management Group Commercial	$100.10
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: University Health Alliance Commercial	$80.08

Elbow Orthosis, rigid, w/o joint, prefab, OTS (counterforce)

Facility

$143.00

Service Code	HCPCS L3762
Hospital Charge Code	13381786
Hospital Revenue Code	274
Min. Negotiated Rate	$46.13
Max. Negotiated Rate	$138.71
Rate for Payer: AlohaCare Medicaid	$71.50
Rate for Payer: AlohaCare Medicare	$71.50
Rate for Payer: Cash Price	$92.95
Rate for Payer: Cash Price	$92.95
Rate for Payer: Devoted Health Medicare	$78.65
Rate for Payer: Hawaii Medical Service Association Medicare	$71.50
Rate for Payer: Hawaii Western Management Group Commercial	$100.10
Rate for Payer: Health Management Network Commercial	$121.55
Rate for Payer: Humana Medicare	$71.50
Rate for Payer: Kaiser Permanente Commercial	$128.70
Rate for Payer: Kaiser Permanente Medicaid	$72.93
Rate for Payer: Kaiser Permanente Medicare	$71.50
Rate for Payer: MDX Hawaii PPO	$138.71
Rate for Payer: Ohana Health Plan Medicaid	$71.50
Rate for Payer: Ohana Health Plan Medicare	$71.50
Rate for Payer: UnitedHealthcare Medicaid	$46.13
Rate for Payer: UnitedHealthcare Medicare	$71.50
Rate for Payer: University Health Alliance Commercial	$80.08

Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - long)

Facility

$213.00

Service Code	HCPCS L3762
Hospital Charge Code	13381792
Hospital Revenue Code	274
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$138.45
Rate for Payer: Hawaii Western Management Group Commercial	$149.10
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$191.70
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: University Health Alliance Commercial	$119.28

Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - long)

Facility

$213.00

Service Code	HCPCS L3762
Hospital Charge Code	13381792
Hospital Revenue Code	274
Min. Negotiated Rate	$46.13
Max. Negotiated Rate	$206.61
Rate for Payer: AlohaCare Medicaid	$106.50
Rate for Payer: AlohaCare Medicare	$106.50
Rate for Payer: Cash Price	$138.45
Rate for Payer: Cash Price	$138.45
Rate for Payer: Devoted Health Medicare	$117.15
Rate for Payer: Hawaii Medical Service Association Medicare	$106.50
Rate for Payer: Hawaii Western Management Group Commercial	$149.10
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Humana Medicare	$106.50
Rate for Payer: Kaiser Permanente Commercial	$191.70
Rate for Payer: Kaiser Permanente Medicaid	$108.63
Rate for Payer: Kaiser Permanente Medicare	$106.50
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: Ohana Health Plan Medicaid	$106.50
Rate for Payer: Ohana Health Plan Medicare	$106.50
Rate for Payer: UnitedHealthcare Medicaid	$46.13
Rate for Payer: UnitedHealthcare Medicare	$106.50
Rate for Payer: University Health Alliance Commercial	$119.28

Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - short)

Facility

$213.00

Service Code	HCPCS L3762
Hospital Charge Code	13381787
Hospital Revenue Code	274
Min. Negotiated Rate	$46.13
Max. Negotiated Rate	$206.61
Rate for Payer: AlohaCare Medicaid	$106.50
Rate for Payer: AlohaCare Medicare	$106.50
Rate for Payer: Cash Price	$138.45
Rate for Payer: Cash Price	$138.45
Rate for Payer: Devoted Health Medicare	$117.15
Rate for Payer: Hawaii Medical Service Association Medicare	$106.50
Rate for Payer: Hawaii Western Management Group Commercial	$149.10
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Humana Medicare	$106.50
Rate for Payer: Kaiser Permanente Commercial	$191.70
Rate for Payer: Kaiser Permanente Medicaid	$108.63
Rate for Payer: Kaiser Permanente Medicare	$106.50
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: Ohana Health Plan Medicaid	$106.50
Rate for Payer: Ohana Health Plan Medicare	$106.50
Rate for Payer: UnitedHealthcare Medicaid	$46.13
Rate for Payer: UnitedHealthcare Medicare	$106.50
Rate for Payer: University Health Alliance Commercial	$119.28

Elbow Orthosis, rigid, w/o joint, prefab, OTS (cubital comfort - short)

Facility

$213.00

Service Code	HCPCS L3762
Hospital Charge Code	13381787
Hospital Revenue Code	274
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$138.45
Rate for Payer: Hawaii Western Management Group Commercial	$149.10
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$191.70
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: University Health Alliance Commercial	$119.28

Electrolytes FSI

Facility

$97.00

Service Code	HCPCS 80051
Hospital Charge Code	8117904
Hospital Revenue Code	301
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$48.50
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Devoted Health Medicare	$53.35
Rate for Payer: Hawaii Medical Service Association ABD	$9.69
Rate for Payer: Hawaii Medical Service Association Commercial	$8.76
Rate for Payer: Hawaii Medical Service Association Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.17
Rate for Payer: Hawaii Western Management Group Commercial	$7.01
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$48.50
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$48.50
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$9.69
Rate for Payer: UnitedHealthcare Medicare	$48.50
Rate for Payer: University Health Alliance Commercial	$18.13

Know your out-of-pocket cost for care.

All Charges