Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

GC Screen

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12499896
Hospital Revenue Code	306
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

GC Screen

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12499896
Hospital Revenue Code	306
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association ABD	$9.16
Rate for Payer: Hawaii Medical Service Association Commercial	$8.29
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.62
Rate for Payer: Hawaii Western Management Group Commercial	$6.63
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$17.13

GC Screen- Bill only

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12528424
Hospital Revenue Code	306
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

GC Screen- Bill only

Facility

$66.00

Service Code	HCPCS 87081
Hospital Charge Code	12528424
Hospital Revenue Code	306
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association ABD	$9.16
Rate for Payer: Hawaii Medical Service Association Commercial	$8.29
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.62
Rate for Payer: Hawaii Western Management Group Commercial	$6.63
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$17.13

GEN:COMPOSITE MESH 30CM X 20CM

Facility

$3,036.00

Service Code	HCPCS C1781
Hospital Charge Code	12915049
Hospital Revenue Code	278
Min. Negotiated Rate	$1,700.16
Max. Negotiated Rate	$2,944.92
Rate for Payer: Cash Price	$1,973.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,125.20
Rate for Payer: Health Management Network Commercial	$2,580.60
Rate for Payer: Kaiser Permanente Commercial	$2,732.40
Rate for Payer: MDX Hawaii PPO	$2,944.92
Rate for Payer: University Health Alliance Commercial	$1,700.16

GEN:COMPOSITE MESH 30CM X 20CM

Facility

$3,036.00

Service Code	HCPCS C1781
Hospital Charge Code	12915049
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.00
Max. Negotiated Rate	$2,944.92
Rate for Payer: AlohaCare Medicaid	$1,518.00
Rate for Payer: AlohaCare Medicare	$1,518.00
Rate for Payer: Cash Price	$1,973.40
Rate for Payer: Devoted Health Medicare	$1,669.80
Rate for Payer: Hawaii Medical Service Association Medicare	$1,518.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,125.20
Rate for Payer: Health Management Network Commercial	$2,580.60
Rate for Payer: Humana Medicare	$1,518.00
Rate for Payer: Kaiser Permanente Commercial	$2,732.40
Rate for Payer: Kaiser Permanente Medicaid	$1,548.36
Rate for Payer: Kaiser Permanente Medicare	$1,518.00
Rate for Payer: MDX Hawaii PPO	$2,944.92
Rate for Payer: Ohana Health Plan Medicaid	$1,518.00
Rate for Payer: Ohana Health Plan Medicare	$1,518.00
Rate for Payer: UnitedHealthcare Medicare	$1,518.00
Rate for Payer: University Health Alliance Commercial	$1,700.16

GEN ENDOSCOPIC: ECHELON 45MM RELOAD

Facility

$2,417.00

Hospital Charge Code	10050580
Hospital Revenue Code	272
Min. Negotiated Rate	$1,208.50
Max. Negotiated Rate	$2,344.49
Rate for Payer: AlohaCare Medicaid	$1,208.50
Rate for Payer: AlohaCare Medicare	$1,208.50
Rate for Payer: Cash Price	$1,571.05
Rate for Payer: Devoted Health Medicare	$1,329.35
Rate for Payer: Hawaii Medical Service Association Medicare	$1,208.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,296.15
Rate for Payer: Health Management Network Commercial	$2,054.45
Rate for Payer: Humana Medicare	$1,208.50
Rate for Payer: Kaiser Permanente Commercial	$2,175.30
Rate for Payer: Kaiser Permanente Medicaid	$1,232.67
Rate for Payer: Kaiser Permanente Medicare	$1,208.50
Rate for Payer: MDX Hawaii PPO	$2,344.49
Rate for Payer: Ohana Health Plan Medicaid	$1,208.50
Rate for Payer: Ohana Health Plan Medicare	$1,208.50
Rate for Payer: UnitedHealthcare Medicare	$1,208.50
Rate for Payer: University Health Alliance Commercial	$1,761.75

GEN ENDOSCOPIC: ECHELON 45MM RELOAD

Facility

$2,417.00

Hospital Charge Code	10050580
Hospital Revenue Code	272
Min. Negotiated Rate	$2,054.45
Max. Negotiated Rate	$2,344.49
Rate for Payer: Cash Price	$1,571.05
Rate for Payer: Health Management Network Commercial	$2,054.45
Rate for Payer: Kaiser Permanente Commercial	$2,175.30
Rate for Payer: MDX Hawaii PPO	$2,344.49

GEN ENDOSCOPIC: ENDOLOOP PDS II LIGATURE 18

Facility

$767.00

Hospital Charge Code	10050581
Hospital Revenue Code	272
Min. Negotiated Rate	$651.95
Max. Negotiated Rate	$743.99
Rate for Payer: Cash Price	$498.55
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: MDX Hawaii PPO	$743.99

GEN ENDOSCOPIC: ENDOLOOP PDS II LIGATURE 18

Facility

$767.00

Hospital Charge Code	10050581
Hospital Revenue Code	272
Min. Negotiated Rate	$383.50
Max. Negotiated Rate	$743.99
Rate for Payer: AlohaCare Medicaid	$383.50
Rate for Payer: AlohaCare Medicare	$383.50
Rate for Payer: Cash Price	$498.55
Rate for Payer: Devoted Health Medicare	$421.85
Rate for Payer: Hawaii Medical Service Association Medicare	$383.50
Rate for Payer: Hawaii Western Management Group Commercial	$728.65
Rate for Payer: Health Management Network Commercial	$651.95
Rate for Payer: Humana Medicare	$383.50
Rate for Payer: Kaiser Permanente Commercial	$690.30
Rate for Payer: Kaiser Permanente Medicaid	$391.17
Rate for Payer: Kaiser Permanente Medicare	$383.50
Rate for Payer: MDX Hawaii PPO	$743.99
Rate for Payer: Ohana Health Plan Medicaid	$383.50
Rate for Payer: Ohana Health Plan Medicare	$383.50
Rate for Payer: UnitedHealthcare Medicare	$383.50
Rate for Payer: University Health Alliance Commercial	$559.07

GENERAL:BINDER BREAST LARGE

Facility

$278.00

Hospital Charge Code	11398984
Hospital Revenue Code	272
Min. Negotiated Rate	$139.00
Max. Negotiated Rate	$269.66
Rate for Payer: AlohaCare Medicaid	$139.00
Rate for Payer: AlohaCare Medicare	$139.00
Rate for Payer: Cash Price	$180.70
Rate for Payer: Devoted Health Medicare	$152.90
Rate for Payer: Hawaii Medical Service Association Medicare	$139.00
Rate for Payer: Hawaii Western Management Group Commercial	$264.10
Rate for Payer: Health Management Network Commercial	$236.30
Rate for Payer: Humana Medicare	$139.00
Rate for Payer: Kaiser Permanente Commercial	$250.20
Rate for Payer: Kaiser Permanente Medicaid	$141.78
Rate for Payer: Kaiser Permanente Medicare	$139.00
Rate for Payer: MDX Hawaii PPO	$269.66
Rate for Payer: Ohana Health Plan Medicaid	$139.00
Rate for Payer: Ohana Health Plan Medicare	$139.00
Rate for Payer: UnitedHealthcare Medicare	$139.00
Rate for Payer: University Health Alliance Commercial	$202.63

GENERAL:BINDER BREAST LARGE

Facility

$278.00

Hospital Charge Code	11398984
Hospital Revenue Code	272
Min. Negotiated Rate	$236.30
Max. Negotiated Rate	$269.66
Rate for Payer: Cash Price	$180.70
Rate for Payer: Health Management Network Commercial	$236.30
Rate for Payer: Kaiser Permanente Commercial	$250.20
Rate for Payer: MDX Hawaii PPO	$269.66

GENERAL:CANISTER 150 ML

Facility

$237.00

Hospital Charge Code	12818167
Hospital Revenue Code	272
Min. Negotiated Rate	$201.45
Max. Negotiated Rate	$229.89
Rate for Payer: Cash Price	$154.05
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: MDX Hawaii PPO	$229.89

GENERAL:CANISTER 150 ML

Facility

$237.00

Hospital Charge Code	12818167
Hospital Revenue Code	272
Min. Negotiated Rate	$118.50
Max. Negotiated Rate	$229.89
Rate for Payer: AlohaCare Medicaid	$118.50
Rate for Payer: AlohaCare Medicare	$118.50
Rate for Payer: Cash Price	$154.05
Rate for Payer: Devoted Health Medicare	$130.35
Rate for Payer: Hawaii Medical Service Association Medicare	$118.50
Rate for Payer: Hawaii Western Management Group Commercial	$225.15
Rate for Payer: Health Management Network Commercial	$201.45
Rate for Payer: Humana Medicare	$118.50
Rate for Payer: Kaiser Permanente Commercial	$213.30
Rate for Payer: Kaiser Permanente Medicaid	$120.87
Rate for Payer: Kaiser Permanente Medicare	$118.50
Rate for Payer: MDX Hawaii PPO	$229.89
Rate for Payer: Ohana Health Plan Medicaid	$118.50
Rate for Payer: Ohana Health Plan Medicare	$118.50
Rate for Payer: UnitedHealthcare Medicare	$118.50
Rate for Payer: University Health Alliance Commercial	$172.75

GENERAL:CANISTER 45 ML 7.2 X 6

Facility

$214.00

Hospital Charge Code	12818174
Hospital Revenue Code	272
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

GENERAL:CANISTER 45 ML 7.2 X 6

Facility

$214.00

Hospital Charge Code	12818174
Hospital Revenue Code	272
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$207.58
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$155.98

GENERAL:CARTER-THOMASON 12MM

Facility

$658.00

Hospital Charge Code	13217011
Hospital Revenue Code	272
Min. Negotiated Rate	$559.30
Max. Negotiated Rate	$638.26
Rate for Payer: Cash Price	$427.70
Rate for Payer: Health Management Network Commercial	$559.30
Rate for Payer: Kaiser Permanente Commercial	$592.20
Rate for Payer: MDX Hawaii PPO	$638.26

GENERAL:CARTER-THOMASON 12MM

Facility

$658.00

Hospital Charge Code	13217011
Hospital Revenue Code	272
Min. Negotiated Rate	$329.00
Max. Negotiated Rate	$638.26
Rate for Payer: AlohaCare Medicaid	$329.00
Rate for Payer: AlohaCare Medicare	$329.00
Rate for Payer: Cash Price	$427.70
Rate for Payer: Devoted Health Medicare	$361.90
Rate for Payer: Hawaii Medical Service Association Medicare	$329.00
Rate for Payer: Hawaii Western Management Group Commercial	$625.10
Rate for Payer: Health Management Network Commercial	$559.30
Rate for Payer: Humana Medicare	$329.00
Rate for Payer: Kaiser Permanente Commercial	$592.20
Rate for Payer: Kaiser Permanente Medicaid	$335.58
Rate for Payer: Kaiser Permanente Medicare	$329.00
Rate for Payer: MDX Hawaii PPO	$638.26
Rate for Payer: Ohana Health Plan Medicaid	$329.00
Rate for Payer: Ohana Health Plan Medicare	$329.00
Rate for Payer: UnitedHealthcare Medicare	$329.00
Rate for Payer: University Health Alliance Commercial	$479.62

GENERAL:COMPOSITE MESH 42 X 32 CM

Facility

$3,614.00

Service Code	HCPCS C1781
Hospital Charge Code	13021712
Hospital Revenue Code	278
Min. Negotiated Rate	$1,807.00
Max. Negotiated Rate	$3,505.58
Rate for Payer: AlohaCare Medicaid	$1,807.00
Rate for Payer: AlohaCare Medicare	$1,807.00
Rate for Payer: Cash Price	$2,349.10
Rate for Payer: Devoted Health Medicare	$1,987.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1,807.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,529.80
Rate for Payer: Health Management Network Commercial	$3,071.90
Rate for Payer: Humana Medicare	$1,807.00
Rate for Payer: Kaiser Permanente Commercial	$3,252.60
Rate for Payer: Kaiser Permanente Medicaid	$1,843.14
Rate for Payer: Kaiser Permanente Medicare	$1,807.00
Rate for Payer: MDX Hawaii PPO	$3,505.58
Rate for Payer: Ohana Health Plan Medicaid	$1,807.00
Rate for Payer: Ohana Health Plan Medicare	$1,807.00
Rate for Payer: UnitedHealthcare Medicare	$1,807.00
Rate for Payer: University Health Alliance Commercial	$2,023.84

GENERAL:COMPOSITE MESH 42 X 32 CM

Facility

$3,614.00

Service Code	HCPCS C1781
Hospital Charge Code	13021712
Hospital Revenue Code	278
Min. Negotiated Rate	$2,023.84
Max. Negotiated Rate	$3,505.58
Rate for Payer: Cash Price	$2,349.10
Rate for Payer: Hawaii Western Management Group Commercial	$2,529.80
Rate for Payer: Health Management Network Commercial	$3,071.90
Rate for Payer: Kaiser Permanente Commercial	$3,252.60
Rate for Payer: MDX Hawaii PPO	$3,505.58
Rate for Payer: University Health Alliance Commercial	$2,023.84

GENERAL: DERMABOND MINI

Facility

$72.00

Hospital Charge Code	13287182
Hospital Revenue Code	272
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

GENERAL: DERMABOND MINI

Facility

$72.00

Hospital Charge Code	13287182
Hospital Revenue Code	272
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$36.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Devoted Health Medicare	$39.60
Rate for Payer: Hawaii Medical Service Association Medicare	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$36.00
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$36.00
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$36.00
Rate for Payer: Ohana Health Plan Medicare	$36.00
Rate for Payer: UnitedHealthcare Medicare	$36.00
Rate for Payer: University Health Alliance Commercial	$52.48

GENERAL:DRESSING ADAPTIC

Facility

$18.00

Hospital Charge Code	12818173
Hospital Revenue Code	272
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

GENERAL:DRESSING ADAPTIC

Facility

$18.00

Hospital Charge Code	12818173
Hospital Revenue Code	272
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$9.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.00
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$9.00
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$9.00
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$9.00
Rate for Payer: Ohana Health Plan Medicare	$9.00
Rate for Payer: UnitedHealthcare Medicare	$9.00
Rate for Payer: University Health Alliance Commercial	$13.12

GENERAL:ENDOCLOSE TROCAR SITE CLOSURE

Facility

$134.00

Hospital Charge Code	13217014
Hospital Revenue Code	272
Min. Negotiated Rate	$67.00
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: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Western Management Group Commercial	$127.30
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 Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$97.67

Know your out-of-pocket cost for care.

All Charges