Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

GI CATHETER, NEEDLE INTERJECT

Facility

$152.00

Hospital Charge Code	8274152
Hospital Revenue Code	272
Min. Negotiated Rate	$129.20
Max. Negotiated Rate	$147.44
Rate for Payer: Cash Price	$98.80
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: MDX Hawaii PPO	$147.44

GI ENDOSCOPY BIOPSY FORCEP/COLD 160

Facility

$64.00

Hospital Charge Code	8274429
Hospital Revenue Code	272
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$62.08
Rate for Payer: AlohaCare Medicaid	$32.00
Rate for Payer: AlohaCare Medicare	$32.00
Rate for Payer: Cash Price	$41.60
Rate for Payer: Devoted Health Medicare	$35.20
Rate for Payer: Hawaii Medical Service Association Medicare	$32.00
Rate for Payer: Hawaii Western Management Group Commercial	$60.80
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Humana Medicare	$32.00
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: Kaiser Permanente Medicaid	$32.64
Rate for Payer: Kaiser Permanente Medicare	$32.00
Rate for Payer: MDX Hawaii PPO	$62.08
Rate for Payer: Ohana Health Plan Medicaid	$32.00
Rate for Payer: Ohana Health Plan Medicare	$32.00
Rate for Payer: UnitedHealthcare Medicare	$32.00
Rate for Payer: University Health Alliance Commercial	$46.65

GI ENDOSCOPY BIOPSY FORCEP/COLD 160

Facility

$64.00

Hospital Charge Code	8274429
Hospital Revenue Code	272
Min. Negotiated Rate	$54.40
Max. Negotiated Rate	$62.08
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Kaiser Permanente Commercial	$57.60
Rate for Payer: MDX Hawaii PPO	$62.08

GI ENDOSCOPY BIOPSY FORCEP/COLD 240

Facility

$92.00

Hospital Charge Code	8274216
Hospital Revenue Code	272
Min. Negotiated Rate	$46.00
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Western Management Group Commercial	$87.40
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$67.06

GI ENDOSCOPY BIOPSY FORCEP/COLD 240

Facility

$92.00

Hospital Charge Code	8274216
Hospital Revenue Code	272
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

GI ENDOSCOPY INJECTION GOLD PROBE 7 FRENCH

Facility

$788.00

Hospital Charge Code	8274153
Hospital Revenue Code	272
Min. Negotiated Rate	$669.80
Max. Negotiated Rate	$764.36
Rate for Payer: Cash Price	$512.20
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: MDX Hawaii PPO	$764.36

GI ENDOSCOPY INJECTION GOLD PROBE 7 FRENCH

Facility

$788.00

Hospital Charge Code	8274153
Hospital Revenue Code	272
Min. Negotiated Rate	$394.00
Max. Negotiated Rate	$764.36
Rate for Payer: AlohaCare Medicaid	$394.00
Rate for Payer: AlohaCare Medicare	$394.00
Rate for Payer: Cash Price	$512.20
Rate for Payer: Devoted Health Medicare	$433.40
Rate for Payer: Hawaii Medical Service Association Medicare	$394.00
Rate for Payer: Hawaii Western Management Group Commercial	$748.60
Rate for Payer: Health Management Network Commercial	$669.80
Rate for Payer: Humana Medicare	$394.00
Rate for Payer: Kaiser Permanente Commercial	$709.20
Rate for Payer: Kaiser Permanente Medicaid	$401.88
Rate for Payer: Kaiser Permanente Medicare	$394.00
Rate for Payer: MDX Hawaii PPO	$764.36
Rate for Payer: Ohana Health Plan Medicaid	$394.00
Rate for Payer: Ohana Health Plan Medicare	$394.00
Rate for Payer: UnitedHealthcare Medicare	$394.00
Rate for Payer: University Health Alliance Commercial	$574.37

GI ENDOSCOPY RESCUE NET RETRIEVAL

Facility

$340.00

Hospital Charge Code	10510251
Hospital Revenue Code	272
Min. Negotiated Rate	$289.00
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$221.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$329.80

GI ENDOSCOPY RESCUE NET RETRIEVAL

Facility

$340.00

Hospital Charge Code	10510251
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$329.80
Rate for Payer: AlohaCare Medicaid	$170.00
Rate for Payer: AlohaCare Medicare	$170.00
Rate for Payer: Cash Price	$221.00
Rate for Payer: Devoted Health Medicare	$187.00
Rate for Payer: Hawaii Medical Service Association Medicare	$170.00
Rate for Payer: Hawaii Western Management Group Commercial	$323.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Humana Medicare	$170.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: Kaiser Permanente Medicaid	$173.40
Rate for Payer: Kaiser Permanente Medicare	$170.00
Rate for Payer: MDX Hawaii PPO	$329.80
Rate for Payer: Ohana Health Plan Medicaid	$170.00
Rate for Payer: Ohana Health Plan Medicare	$170.00
Rate for Payer: UnitedHealthcare Medicare	$170.00
Rate for Payer: University Health Alliance Commercial	$247.83

GI GASTRO POLYP TRAP

Facility

$14.00

Hospital Charge Code	8274346
Hospital Revenue Code	272
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$7.00
Rate for Payer: Cash Price	$9.10
Rate for Payer: Devoted Health Medicare	$7.70
Rate for Payer: Hawaii Medical Service Association Medicare	$7.00
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$7.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$7.00
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$7.00
Rate for Payer: Ohana Health Plan Medicare	$7.00
Rate for Payer: UnitedHealthcare Medicare	$7.00
Rate for Payer: University Health Alliance Commercial	$10.20

GI GASTRO POLYP TRAP

Facility

$14.00

Hospital Charge Code	8274346
Hospital Revenue Code	272
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$9.10
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

GI: INFLATOR FOR BALLOON 60CC

Facility

$190.00

Hospital Charge Code	9953066
Hospital Revenue Code	272
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$184.30
Rate for Payer: Cash Price	$123.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: MDX Hawaii PPO	$184.30

GI: INFLATOR FOR BALLOON 60CC

Facility

$190.00

Hospital Charge Code	9953066
Hospital Revenue Code	272
Min. Negotiated Rate	$95.00
Max. Negotiated Rate	$184.30
Rate for Payer: AlohaCare Medicaid	$95.00
Rate for Payer: AlohaCare Medicare	$95.00
Rate for Payer: Cash Price	$123.50
Rate for Payer: Devoted Health Medicare	$104.50
Rate for Payer: Hawaii Medical Service Association Medicare	$95.00
Rate for Payer: Hawaii Western Management Group Commercial	$180.50
Rate for Payer: Health Management Network Commercial	$161.50
Rate for Payer: Humana Medicare	$95.00
Rate for Payer: Kaiser Permanente Commercial	$171.00
Rate for Payer: Kaiser Permanente Medicaid	$96.90
Rate for Payer: Kaiser Permanente Medicare	$95.00
Rate for Payer: MDX Hawaii PPO	$184.30
Rate for Payer: Ohana Health Plan Medicaid	$95.00
Rate for Payer: Ohana Health Plan Medicare	$95.00
Rate for Payer: UnitedHealthcare Medicare	$95.00
Rate for Payer: University Health Alliance Commercial	$138.49

GI Panel PCR FSI

Facility

$3,849.00

Service Code	HCPCS 87999
Hospital Charge Code	8695016
Hospital Revenue Code	306
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$3,733.53
Rate for Payer: AlohaCare Medicaid	$1,924.50
Rate for Payer: AlohaCare Medicare	$1,924.50
Rate for Payer: Cash Price	$2,501.85
Rate for Payer: Cash Price	$2,501.85
Rate for Payer: Devoted Health Medicare	$2,116.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1,924.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,656.55
Rate for Payer: Health Management Network Commercial	$3,271.65
Rate for Payer: Humana Medicare	$1,924.50
Rate for Payer: Kaiser Permanente Commercial	$3,464.10
Rate for Payer: Kaiser Permanente Medicaid	$1,962.99
Rate for Payer: Kaiser Permanente Medicare	$1,924.50
Rate for Payer: MDX Hawaii PPO	$3,733.53
Rate for Payer: Ohana Health Plan Medicaid	$1,924.50
Rate for Payer: Ohana Health Plan Medicare	$1,924.50
Rate for Payer: UnitedHealthcare Medicaid	$7.90
Rate for Payer: UnitedHealthcare Medicare	$1,924.50
Rate for Payer: University Health Alliance Commercial	$2,805.54

GI Panel PCR FSI

Facility

$3,849.00

Service Code	HCPCS 87999
Hospital Charge Code	8695016
Hospital Revenue Code	306
Min. Negotiated Rate	$3,271.65
Max. Negotiated Rate	$3,733.53
Rate for Payer: Cash Price	$2,501.85
Rate for Payer: Health Management Network Commercial	$3,271.65
Rate for Payer: Kaiser Permanente Commercial	$3,464.10
Rate for Payer: MDX Hawaii PPO	$3,733.53

GI QUICKCLIP PRO

Facility

$735.00

Hospital Charge Code	9952984
Hospital Revenue Code	272
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$712.95
Rate for Payer: AlohaCare Medicaid	$367.50
Rate for Payer: AlohaCare Medicare	$367.50
Rate for Payer: Cash Price	$477.75
Rate for Payer: Devoted Health Medicare	$404.25
Rate for Payer: Hawaii Medical Service Association Medicare	$367.50
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Humana Medicare	$367.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: Kaiser Permanente Medicare	$367.50
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: Ohana Health Plan Medicaid	$367.50
Rate for Payer: Ohana Health Plan Medicare	$367.50
Rate for Payer: UnitedHealthcare Medicare	$367.50
Rate for Payer: University Health Alliance Commercial	$535.74

GI QUICKCLIP PRO

Facility

$735.00

Hospital Charge Code	9952984
Hospital Revenue Code	272
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$477.75
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: MDX Hawaii PPO	$712.95

GI: RADIAL JAW (HOT) 240CM

Facility

$115.00

Hospital Charge Code	9953068
Hospital Revenue Code	272
Min. Negotiated Rate	$57.50
Max. Negotiated Rate	$111.55
Rate for Payer: AlohaCare Medicaid	$57.50
Rate for Payer: AlohaCare Medicare	$57.50
Rate for Payer: Cash Price	$74.75
Rate for Payer: Devoted Health Medicare	$63.25
Rate for Payer: Hawaii Medical Service Association Medicare	$57.50
Rate for Payer: Hawaii Western Management Group Commercial	$109.25
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Humana Medicare	$57.50
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: Kaiser Permanente Medicare	$57.50
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: Ohana Health Plan Medicaid	$57.50
Rate for Payer: Ohana Health Plan Medicare	$57.50
Rate for Payer: UnitedHealthcare Medicare	$57.50
Rate for Payer: University Health Alliance Commercial	$83.82

GI: RADIAL JAW (HOT) 240CM

Facility

$115.00

Hospital Charge Code	9953068
Hospital Revenue Code	272
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$74.75
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: MDX Hawaii PPO	$111.55

GI: RESOLUTION CLIP 360 - 235CM

Facility

$822.00

Hospital Charge Code	9953046
Hospital Revenue Code	272
Min. Negotiated Rate	$411.00
Max. Negotiated Rate	$797.34
Rate for Payer: AlohaCare Medicaid	$411.00
Rate for Payer: AlohaCare Medicare	$411.00
Rate for Payer: Cash Price	$534.30
Rate for Payer: Devoted Health Medicare	$452.10
Rate for Payer: Hawaii Medical Service Association Medicare	$411.00
Rate for Payer: Hawaii Western Management Group Commercial	$780.90
Rate for Payer: Health Management Network Commercial	$698.70
Rate for Payer: Humana Medicare	$411.00
Rate for Payer: Kaiser Permanente Commercial	$739.80
Rate for Payer: Kaiser Permanente Medicaid	$419.22
Rate for Payer: Kaiser Permanente Medicare	$411.00
Rate for Payer: MDX Hawaii PPO	$797.34
Rate for Payer: Ohana Health Plan Medicaid	$411.00
Rate for Payer: Ohana Health Plan Medicare	$411.00
Rate for Payer: UnitedHealthcare Medicare	$411.00
Rate for Payer: University Health Alliance Commercial	$599.16

GI: RESOLUTION CLIP 360 - 235CM

Facility

$822.00

Hospital Charge Code	9953046
Hospital Revenue Code	272
Min. Negotiated Rate	$698.70
Max. Negotiated Rate	$797.34
Rate for Payer: Cash Price	$534.30
Rate for Payer: Health Management Network Commercial	$698.70
Rate for Payer: Kaiser Permanente Commercial	$739.80
Rate for Payer: MDX Hawaii PPO	$797.34

GI SNARE CAPTIVATION LARGE 30MM

Facility

$24.00

Hospital Charge Code	9542824
Hospital Revenue Code	272
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$17.49

GI SNARE CAPTIVATION LARGE 30MM

Facility

$24.00

Hospital Charge Code	9542824
Hospital Revenue Code	272
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

GI SNARE CAPTIVATOR LARGE OVAL (THIN WIRE) 30MM LARGE SNARE

Facility

$523.00

Hospital Charge Code	9595418
Hospital Revenue Code	272
Min. Negotiated Rate	$261.50
Max. Negotiated Rate	$507.31
Rate for Payer: AlohaCare Medicaid	$261.50
Rate for Payer: AlohaCare Medicare	$261.50
Rate for Payer: Cash Price	$339.95
Rate for Payer: Devoted Health Medicare	$287.65
Rate for Payer: Hawaii Medical Service Association Medicare	$261.50
Rate for Payer: Hawaii Western Management Group Commercial	$496.85
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Humana Medicare	$261.50
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: Kaiser Permanente Medicaid	$266.73
Rate for Payer: Kaiser Permanente Medicare	$261.50
Rate for Payer: MDX Hawaii PPO	$507.31
Rate for Payer: Ohana Health Plan Medicaid	$261.50
Rate for Payer: Ohana Health Plan Medicare	$261.50
Rate for Payer: UnitedHealthcare Medicare	$261.50
Rate for Payer: University Health Alliance Commercial	$381.21

GI SNARE CAPTIVATOR LARGE OVAL (THIN WIRE) 30MM LARGE SNARE

Facility

$523.00

Hospital Charge Code	9595418
Hospital Revenue Code	272
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$339.95
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: MDX Hawaii PPO	$507.31

Know your out-of-pocket cost for care.

All Charges