Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Free PSA and Total PSA FSI

Facility

$120.00

Service Code	HCPCS G0103
Hospital Charge Code	8228870
Hospital Revenue Code	300
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

Free PSA and Total PSA FSI

Facility

$120.00

Service Code	HCPCS G0103
Hospital Charge Code	8228870
Hospital Revenue Code	300
Min. Negotiated Rate	$24.14
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$60.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$66.00
Rate for Payer: Hawaii Medical Service Association Commercial	$24.14
Rate for Payer: Hawaii Medical Service Association Medicare	$60.00
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$60.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$60.00
Rate for Payer: Ohana Health Plan Medicare	$60.00
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$87.47

Free PSA FSI

Facility

$134.00

Service Code	HCPCS 84154
Hospital Charge Code	8191165
Hospital Revenue Code	300
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

Free PSA FSI

Facility

$134.00

Service Code	HCPCS 84154
Hospital Charge Code	8191165
Hospital Revenue Code	300
Min. Negotiated Rate	$18.39
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: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association ABD	$25.42
Rate for Payer: Hawaii Medical Service Association Commercial	$22.99
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.69
Rate for Payer: Hawaii Western Management Group Commercial	$18.39
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 Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$47.55

Free T4 FSI

Facility

$266.00

Service Code	HCPCS 84439
Hospital Charge Code	8117915
Hospital Revenue Code	301
Min. Negotiated Rate	$226.10
Max. Negotiated Rate	$258.02
Rate for Payer: Cash Price	$172.90
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: MDX Hawaii PPO	$258.02

Free T4 FSI

Facility

$266.00

Service Code	HCPCS 84439
Hospital Charge Code	8117915
Hospital Revenue Code	301
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$258.02
Rate for Payer: AlohaCare Medicaid	$133.00
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$172.90
Rate for Payer: Cash Price	$172.90
Rate for Payer: Devoted Health Medicare	$146.30
Rate for Payer: Hawaii Medical Service Association ABD	$12.46
Rate for Payer: Hawaii Medical Service Association Commercial	$11.28
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13.08
Rate for Payer: Hawaii Western Management Group Commercial	$9.02
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$135.66
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$258.02
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicaid	$12.46
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$23.31

Fructosamine FSI

Facility

$173.00

Service Code	HCPCS 82985
Hospital Charge Code	8117916
Hospital Revenue Code	301
Min. Negotiated Rate	$147.05
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$112.45
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$167.81

Fructosamine FSI

Facility

$173.00

Service Code	HCPCS 82985
Hospital Charge Code	8117916
Hospital Revenue Code	301
Min. Negotiated Rate	$16.76
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicare	$86.50
Rate for Payer: Cash Price	$112.45
Rate for Payer: Cash Price	$112.45
Rate for Payer: Devoted Health Medicare	$95.15
Rate for Payer: Hawaii Medical Service Association ABD	$20.83
Rate for Payer: Hawaii Medical Service Association Commercial	$20.95
Rate for Payer: Hawaii Medical Service Association Medicare	$86.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.87
Rate for Payer: Hawaii Western Management Group Commercial	$16.76
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$86.50
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$86.50
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$86.50
Rate for Payer: Ohana Health Plan Medicare	$86.50
Rate for Payer: UnitedHealthcare Medicaid	$20.83
Rate for Payer: UnitedHealthcare Medicare	$86.50
Rate for Payer: University Health Alliance Commercial	$38.96

FSH FSI

Facility

$213.00

Service Code	HCPCS 83001
Hospital Charge Code	8117917
Hospital Revenue Code	301
Min. Negotiated Rate	$18.58
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 ABD	$25.69
Rate for Payer: Hawaii Medical Service Association Commercial	$23.23
Rate for Payer: Hawaii Medical Service Association Medicare	$106.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.97
Rate for Payer: Hawaii Western Management Group Commercial	$18.58
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	$25.69
Rate for Payer: UnitedHealthcare Medicare	$106.50
Rate for Payer: University Health Alliance Commercial	$48.04

FSH FSI

Facility

$213.00

Service Code	HCPCS 83001
Hospital Charge Code	8117917
Hospital Revenue Code	301
Min. Negotiated Rate	$181.05
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$138.45
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

FSI DTA

Facility

$166.00

Service Code	HCPCS 86677
Hospital Charge Code	8585551
Hospital Revenue Code	300
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$161.02
Rate for Payer: AlohaCare Medicaid	$83.00
Rate for Payer: AlohaCare Medicare	$83.00
Rate for Payer: Cash Price	$107.90
Rate for Payer: Cash Price	$107.90
Rate for Payer: Devoted Health Medicare	$91.30
Rate for Payer: Hawaii Medical Service Association ABD	$20.05
Rate for Payer: Hawaii Medical Service Association Commercial	$21.06
Rate for Payer: Hawaii Medical Service Association Medicare	$83.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.05
Rate for Payer: Hawaii Western Management Group Commercial	$16.85
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Humana Medicare	$83.00
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: Kaiser Permanente Medicaid	$84.66
Rate for Payer: Kaiser Permanente Medicare	$83.00
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: Ohana Health Plan Medicaid	$83.00
Rate for Payer: Ohana Health Plan Medicare	$83.00
Rate for Payer: UnitedHealthcare Medicaid	$20.05
Rate for Payer: UnitedHealthcare Medicare	$83.00
Rate for Payer: University Health Alliance Commercial	$37.52

FSI DTA

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8641458
Hospital Revenue Code	300
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

FSI DTA

Facility

$166.00

Service Code	HCPCS 86677
Hospital Charge Code	8585551
Hospital Revenue Code	300
Min. Negotiated Rate	$141.10
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$107.90
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: MDX Hawaii PPO	$161.02

FSI DTA

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8641458
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

FTA-Abs REF

Facility

$151.00

Service Code	HCPCS 86780
Hospital Charge Code	8160078
Hospital Revenue Code	302
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$18.97
Rate for Payer: Hawaii Medical Service Association Commercial	$16.55
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.24
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$18.97
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$35.09

FTA-Abs REF

Facility

$151.00

Service Code	HCPCS 86780
Hospital Charge Code	8160078
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$20,422.30

Service Code	MSDRG 793
Min. Negotiated Rate	$20,422.30
Max. Negotiated Rate	$20,422.30
Rate for Payer: Hawaii Medical Service Association Commercial	$20,422.30

Functional Capacity Eval Charge

Facility

$275.00

Service Code	HCPCS 97750 GP,CQ
Hospital Charge Code	8111734
Hospital Revenue Code	430
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$266.75
Rate for Payer: AlohaCare Medicaid	$137.50
Rate for Payer: AlohaCare Medicare	$137.50
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Devoted Health Medicare	$151.25
Rate for Payer: Hawaii Medical Service Association Medicare	$137.50
Rate for Payer: Hawaii Western Management Group Commercial	$261.25
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Humana Medicare	$137.50
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: Kaiser Permanente Medicaid	$140.25
Rate for Payer: Kaiser Permanente Medicare	$137.50
Rate for Payer: MDX Hawaii PPO	$266.75
Rate for Payer: Ohana Health Plan Medicaid	$137.50
Rate for Payer: Ohana Health Plan Medicare	$137.50
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$137.50
Rate for Payer: University Health Alliance Commercial	$200.45

Functional Capacity Eval Charge

Facility

$275.00

Service Code	HCPCS 97750 GP,CQ
Hospital Charge Code	8111734
Hospital Revenue Code	430
Min. Negotiated Rate	$233.75
Max. Negotiated Rate	$266.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: MDX Hawaii PPO	$266.75

FUNCTIONAL RESIDUAL CAPACTITY CHARGE

Facility

$389.00

Service Code	HCPCS 94727
Hospital Charge Code	8243390
Hospital Revenue Code	460
Min. Negotiated Rate	$330.65
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$252.85
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33

FUNCTIONAL RESIDUAL CAPACTITY CHARGE

Facility

$389.00

Service Code	HCPCS 94727
Hospital Charge Code	8243390
Hospital Revenue Code	460
Min. Negotiated Rate	$20.65
Max. Negotiated Rate	$377.33
Rate for Payer: AlohaCare Medicaid	$194.50
Rate for Payer: AlohaCare Medicare	$194.50
Rate for Payer: Cash Price	$252.85
Rate for Payer: Cash Price	$252.85
Rate for Payer: Devoted Health Medicare	$213.95
Rate for Payer: Hawaii Medical Service Association ABD	$20.65
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$194.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.66
Rate for Payer: Hawaii Western Management Group Commercial	$369.55
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Humana Medicare	$194.50
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: Kaiser Permanente Medicaid	$198.39
Rate for Payer: Kaiser Permanente Medicare	$194.50
Rate for Payer: MDX Hawaii PPO	$377.33
Rate for Payer: Ohana Health Plan Medicaid	$194.50
Rate for Payer: Ohana Health Plan Medicare	$194.50
Rate for Payer: UnitedHealthcare Medicaid	$20.65
Rate for Payer: UnitedHealthcare Medicare	$194.50
Rate for Payer: University Health Alliance Commercial	$283.54

Fungitell 1-3BD Glucan FSI

Facility

$339.00

Service Code	HCPCS 84311
Hospital Charge Code	8228871
Hospital Revenue Code	301
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$328.83
Rate for Payer: AlohaCare Medicaid	$169.50
Rate for Payer: AlohaCare Medicare	$169.50
Rate for Payer: Cash Price	$220.35
Rate for Payer: Cash Price	$220.35
Rate for Payer: Devoted Health Medicare	$186.45
Rate for Payer: Hawaii Medical Service Association ABD	$9.66
Rate for Payer: Hawaii Medical Service Association Commercial	$10.12
Rate for Payer: Hawaii Medical Service Association Medicare	$169.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.14
Rate for Payer: Hawaii Western Management Group Commercial	$8.10
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Humana Medicare	$169.50
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: Kaiser Permanente Medicaid	$172.89
Rate for Payer: Kaiser Permanente Medicare	$169.50
Rate for Payer: MDX Hawaii PPO	$328.83
Rate for Payer: Ohana Health Plan Medicaid	$169.50
Rate for Payer: Ohana Health Plan Medicare	$169.50
Rate for Payer: UnitedHealthcare Medicaid	$9.66
Rate for Payer: UnitedHealthcare Medicare	$169.50
Rate for Payer: University Health Alliance Commercial	$18.07

Fungitell 1-3BD Glucan FSI

Facility

$339.00

Service Code	HCPCS 84311
Hospital Charge Code	8228871
Hospital Revenue Code	301
Min. Negotiated Rate	$288.15
Max. Negotiated Rate	$328.83
Rate for Payer: Cash Price	$220.35
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: MDX Hawaii PPO	$328.83

Fungus/Yeast Cult, Other FSI

Facility

$100.00

Service Code	HCPCS 87102
Hospital Charge Code	8117918
Hospital Revenue Code	306
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$97.00
Rate for Payer: AlohaCare Medicaid	$50.00
Rate for Payer: AlohaCare Medicare	$50.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$55.00
Rate for Payer: Hawaii Medical Service Association ABD	$11.61
Rate for Payer: Hawaii Medical Service Association Commercial	$10.51
Rate for Payer: Hawaii Medical Service Association Medicare	$50.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.19
Rate for Payer: Hawaii Western Management Group Commercial	$8.41
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Humana Medicare	$50.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: Kaiser Permanente Medicaid	$51.00
Rate for Payer: Kaiser Permanente Medicare	$50.00
Rate for Payer: MDX Hawaii PPO	$97.00
Rate for Payer: Ohana Health Plan Medicaid	$50.00
Rate for Payer: Ohana Health Plan Medicare	$50.00
Rate for Payer: UnitedHealthcare Medicaid	$11.61
Rate for Payer: UnitedHealthcare Medicare	$50.00
Rate for Payer: University Health Alliance Commercial	$21.72

Fungus/Yeast Cult, Other FSI

Facility

$100.00

Service Code	HCPCS 87102
Hospital Charge Code	8117918
Hospital Revenue Code	306
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: MDX Hawaii PPO	$97.00

Know your out-of-pocket cost for care.

All Charges