Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM

Facility

$7,085.00

Service Code	CPT 65400
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,085.00
Rate for Payer: AlohaCare Medicaid	$672.48
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$4,035.20

EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT

Facility

$6,743.44

Service Code	CPT 28090
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$1,030.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

EXCISION OF MULTIPLE EXTERNAL PAPILLAE OR TAGS, ANUS

Facility

$3,544.72

Service Code	CPT 46230
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$3,544.72
Rate for Payer: AlohaCare Medicaid	$672.48
Rate for Payer: Hawaii Medical Service Association Commercial	$3,544.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03

EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS;

Facility

$5,655.00

Service Code	CPT 28104
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$5,160.40

EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT

Facility

$7,085.00

Service Code	CPT 65426
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,085.00
Rate for Payer: AlohaCare Medicaid	$1,568.64
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$5,160.40

EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER

Facility

$5,655.00

Service Code	CPT 28039
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,655.00
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$5,160.40

EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; LESS THAN 1.5 CM

Facility

$5,160.40

Service Code	CPT 28043
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: Hawaii Medical Service Association Commercial	$2,109.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$5,160.40

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$66,289.60

Service Code	MSDRG 933
Min. Negotiated Rate	$66,289.60
Max. Negotiated Rate	$66,289.60
Rate for Payer: Hawaii Medical Service Association Commercial	$66,289.60

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$411,454.45

Service Code	MSDRG 927
Min. Negotiated Rate	$411,454.45
Max. Negotiated Rate	$411,454.45
Rate for Payer: Hawaii Medical Service Association Commercial	$411,454.45

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$49,105.30

Service Code	MSDRG 982
Min. Negotiated Rate	$49,105.30
Max. Negotiated Rate	$49,105.30
Rate for Payer: Hawaii Medical Service Association Commercial	$49,105.30

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$82,301.09

Service Code	MSDRG 981
Min. Negotiated Rate	$82,301.09
Max. Negotiated Rate	$82,301.09
Rate for Payer: Hawaii Medical Service Association Commercial	$82,301.09

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$32,583.89

Service Code	MSDRG 983
Min. Negotiated Rate	$32,583.89
Max. Negotiated Rate	$32,583.89
Rate for Payer: Hawaii Medical Service Association Commercial	$32,583.89

EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION

Facility

$11,119.00

Service Code	CPT 66982
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,119.00
Rate for Payer: AlohaCare Medicaid	$2,121.82
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$11,119.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION

Facility

$7,085.00

Service Code	CPT 66984
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,085.00
Rate for Payer: AlohaCare Medicaid	$2,121.82
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

EXTRACRANIAL PROCEDURES WITH CC

Facility

$58,232.86

Service Code	MSDRG 038
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$58,232.86
Rate for Payer: Hawaii Medical Service Association Commercial	$58,232.86
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$69,961.02

Service Code	MSDRG 037
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$69,961.02
Rate for Payer: Hawaii Medical Service Association Commercial	$69,961.02
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$45,331.89

Service Code	MSDRG 039
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$45,331.89
Rate for Payer: Hawaii Medical Service Association Commercial	$45,331.89
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$19,147.50

Service Code	MSDRG 115
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$19,147.50
Rate for Payer: Hawaii Medical Service Association Commercial	$19,147.50
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$292,566.60

Service Code	MSDRG 790
Min. Negotiated Rate	$292,566.60
Max. Negotiated Rate	$292,566.60
Rate for Payer: Hawaii Medical Service Association Commercial	$292,566.60

EYE EXAM† - 00148

Professional

Both

$191.00

Hospital Charge Code	8970861
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

eye irrigation soln (sterile) [HHSC]

Facility

$18.77

Service Code	NDC 10119000252
Hospital Charge Code	2500613
Hospital Revenue Code	250
Min. Negotiated Rate	$9.38
Max. Negotiated Rate	$18.21
Rate for Payer: AlohaCare Medicaid	$9.38
Rate for Payer: AlohaCare Medicare	$9.38
Rate for Payer: Cash Price	$12.20
Rate for Payer: Devoted Health Medicare	$10.32
Rate for Payer: Hawaii Medical Service Association Medicare	$9.38
Rate for Payer: Hawaii Western Management Group Commercial	$17.83
Rate for Payer: Health Management Network Commercial	$15.95
Rate for Payer: Humana Medicare	$9.38
Rate for Payer: Kaiser Permanente Commercial	$16.89
Rate for Payer: Kaiser Permanente Medicaid	$9.57
Rate for Payer: Kaiser Permanente Medicare	$9.38
Rate for Payer: MDX Hawaii PPO	$18.21
Rate for Payer: Ohana Health Plan Medicaid	$9.38
Rate for Payer: Ohana Health Plan Medicare	$9.38
Rate for Payer: UnitedHealthcare Medicaid	$11.26
Rate for Payer: UnitedHealthcare Medicare	$9.38
Rate for Payer: University Health Alliance Commercial	$13.68

eye irrigation soln (sterile) [HHSC]

Facility

$18.77

Service Code	NDC 10119000252
Hospital Charge Code	2500613
Hospital Revenue Code	250
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$18.21
Rate for Payer: Cash Price	$12.20
Rate for Payer: Health Management Network Commercial	$15.95
Rate for Payer: Kaiser Permanente Commercial	$16.89
Rate for Payer: MDX Hawaii PPO	$18.21

Factor VIII Activity FSI

Facility

$290.00

Service Code	HCPCS 85240
Hospital Charge Code	8570989
Hospital Revenue Code	305
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$281.30
Rate for Payer: AlohaCare Medicaid	$145.00
Rate for Payer: AlohaCare Medicare	$145.00
Rate for Payer: Cash Price	$188.50
Rate for Payer: Cash Price	$188.50
Rate for Payer: Devoted Health Medicare	$159.50
Rate for Payer: Hawaii Medical Service Association ABD	$24.75
Rate for Payer: Hawaii Medical Service Association Commercial	$22.38
Rate for Payer: Hawaii Medical Service Association Medicare	$145.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25.99
Rate for Payer: Hawaii Western Management Group Commercial	$17.90
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: Humana Medicare	$145.00
Rate for Payer: Kaiser Permanente Commercial	$261.00
Rate for Payer: Kaiser Permanente Medicaid	$147.90
Rate for Payer: Kaiser Permanente Medicare	$145.00
Rate for Payer: MDX Hawaii PPO	$281.30
Rate for Payer: Ohana Health Plan Medicaid	$145.00
Rate for Payer: Ohana Health Plan Medicare	$145.00
Rate for Payer: UnitedHealthcare Medicaid	$24.75
Rate for Payer: UnitedHealthcare Medicare	$145.00
Rate for Payer: University Health Alliance Commercial	$46.29

Factor VIII Activity FSI

Facility

$290.00

Service Code	HCPCS 85240
Hospital Charge Code	8570989
Hospital Revenue Code	305
Min. Negotiated Rate	$246.50
Max. Negotiated Rate	$281.30
Rate for Payer: Cash Price	$188.50
Rate for Payer: Health Management Network Commercial	$246.50
Rate for Payer: Kaiser Permanente Commercial	$261.00
Rate for Payer: MDX Hawaii PPO	$281.30

Factor V Leiden FSI

Facility

$288.00

Service Code	HCPCS 81241
Hospital Charge Code	11373878
Hospital Revenue Code	309
Min. Negotiated Rate	$47.03
Max. Negotiated Rate	$279.36
Rate for Payer: AlohaCare Medicaid	$144.00
Rate for Payer: AlohaCare Medicare	$144.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cash Price	$187.20
Rate for Payer: Devoted Health Medicare	$158.40
Rate for Payer: Hawaii Medical Service Association ABD	$81.80
Rate for Payer: Hawaii Medical Service Association Commercial	$91.71
Rate for Payer: Hawaii Medical Service Association Medicare	$144.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$81.80
Rate for Payer: Hawaii Western Management Group Commercial	$73.37
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Humana Medicare	$144.00
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: Kaiser Permanente Medicare	$144.00
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: Ohana Health Plan Medicaid	$144.00
Rate for Payer: Ohana Health Plan Medicare	$144.00
Rate for Payer: UnitedHealthcare Medicaid	$47.03
Rate for Payer: UnitedHealthcare Medicare	$144.00
Rate for Payer: University Health Alliance Commercial	$154.23

Know your out-of-pocket cost for care.

All Charges