Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC TechFee

Facility

$450.00

Service Code	HCPCS 29125
Hospital Charge Code	8023337
Hospital Revenue Code	450
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$225.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Devoted Health Medicare	$247.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$225.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$427.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Humana Medicare	$225.00
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$225.00
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: Ohana Health Plan Medicaid	$225.00
Rate for Payer: Ohana Health Plan Medicare	$225.00
Rate for Payer: UnitedHealthcare Medicare	$225.00
Rate for Payer: University Health Alliance Commercial	$328.00

29125 APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC TechFee

Facility

$450.00

Service Code	HCPCS 29125
Hospital Charge Code	8023337
Hospital Revenue Code	450
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$405.00
Rate for Payer: MDX Hawaii PPO	$436.50

29125 Apply Forearm Splint Bilat

Facility

$437.00

Service Code	HCPCS 29125 50
Hospital Charge Code	8222655
Hospital Revenue Code	430
Min. Negotiated Rate	$24.61
Max. Negotiated Rate	$423.89
Rate for Payer: AlohaCare Medicaid	$218.50
Rate for Payer: AlohaCare Medicare	$218.50
Rate for Payer: Cash Price	$284.05
Rate for Payer: Cash Price	$284.05
Rate for Payer: Devoted Health Medicare	$240.35
Rate for Payer: Hawaii Medical Service Association Medicare	$218.50
Rate for Payer: Hawaii Western Management Group Commercial	$415.15
Rate for Payer: Health Management Network Commercial	$371.45
Rate for Payer: Humana Medicare	$218.50
Rate for Payer: Kaiser Permanente Commercial	$393.30
Rate for Payer: Kaiser Permanente Medicaid	$222.87
Rate for Payer: Kaiser Permanente Medicare	$218.50
Rate for Payer: MDX Hawaii PPO	$423.89
Rate for Payer: Ohana Health Plan Medicaid	$218.50
Rate for Payer: Ohana Health Plan Medicare	$218.50
Rate for Payer: UnitedHealthcare Medicaid	$24.61
Rate for Payer: UnitedHealthcare Medicare	$218.50
Rate for Payer: University Health Alliance Commercial	$318.53

29125 Apply Forearm Splint Bilat

Facility

$437.00

Service Code	HCPCS 29125 50
Hospital Charge Code	8222655
Hospital Revenue Code	430
Min. Negotiated Rate	$371.45
Max. Negotiated Rate	$423.89
Rate for Payer: Cash Price	$284.05
Rate for Payer: Health Management Network Commercial	$371.45
Rate for Payer: Kaiser Permanente Commercial	$393.30
Rate for Payer: MDX Hawaii PPO	$423.89

29125 Apply Forearm Splint LT

Facility

$437.00

Service Code	HCPCS 29125 LT
Hospital Charge Code	8222656
Hospital Revenue Code	430
Min. Negotiated Rate	$371.45
Max. Negotiated Rate	$423.89
Rate for Payer: Cash Price	$284.05
Rate for Payer: Health Management Network Commercial	$371.45
Rate for Payer: Kaiser Permanente Commercial	$393.30
Rate for Payer: MDX Hawaii PPO	$423.89

29125 Apply Forearm Splint LT

Facility

$437.00

Service Code	HCPCS 29125 LT
Hospital Charge Code	8222656
Hospital Revenue Code	430
Min. Negotiated Rate	$24.61
Max. Negotiated Rate	$423.89
Rate for Payer: AlohaCare Medicaid	$218.50
Rate for Payer: AlohaCare Medicare	$218.50
Rate for Payer: Cash Price	$284.05
Rate for Payer: Cash Price	$284.05
Rate for Payer: Devoted Health Medicare	$240.35
Rate for Payer: Hawaii Medical Service Association Medicare	$218.50
Rate for Payer: Hawaii Western Management Group Commercial	$415.15
Rate for Payer: Health Management Network Commercial	$371.45
Rate for Payer: Humana Medicare	$218.50
Rate for Payer: Kaiser Permanente Commercial	$393.30
Rate for Payer: Kaiser Permanente Medicaid	$222.87
Rate for Payer: Kaiser Permanente Medicare	$218.50
Rate for Payer: MDX Hawaii PPO	$423.89
Rate for Payer: Ohana Health Plan Medicaid	$218.50
Rate for Payer: Ohana Health Plan Medicare	$218.50
Rate for Payer: UnitedHealthcare Medicaid	$24.61
Rate for Payer: UnitedHealthcare Medicare	$218.50
Rate for Payer: University Health Alliance Commercial	$318.53

29125 Apply Forearm Splint RT

Facility

$437.00

Service Code	HCPCS 29125 RT
Hospital Charge Code	8222657
Hospital Revenue Code	430
Min. Negotiated Rate	$371.45
Max. Negotiated Rate	$423.89
Rate for Payer: Cash Price	$284.05
Rate for Payer: Health Management Network Commercial	$371.45
Rate for Payer: Kaiser Permanente Commercial	$393.30
Rate for Payer: MDX Hawaii PPO	$423.89

29125 Apply Forearm Splint RT

Facility

$437.00

Service Code	HCPCS 29125 RT
Hospital Charge Code	8222657
Hospital Revenue Code	430
Min. Negotiated Rate	$24.61
Max. Negotiated Rate	$423.89
Rate for Payer: AlohaCare Medicaid	$218.50
Rate for Payer: AlohaCare Medicare	$218.50
Rate for Payer: Cash Price	$284.05
Rate for Payer: Cash Price	$284.05
Rate for Payer: Devoted Health Medicare	$240.35
Rate for Payer: Hawaii Medical Service Association Medicare	$218.50
Rate for Payer: Hawaii Western Management Group Commercial	$415.15
Rate for Payer: Health Management Network Commercial	$371.45
Rate for Payer: Humana Medicare	$218.50
Rate for Payer: Kaiser Permanente Commercial	$393.30
Rate for Payer: Kaiser Permanente Medicaid	$222.87
Rate for Payer: Kaiser Permanente Medicare	$218.50
Rate for Payer: MDX Hawaii PPO	$423.89
Rate for Payer: Ohana Health Plan Medicaid	$218.50
Rate for Payer: Ohana Health Plan Medicare	$218.50
Rate for Payer: UnitedHealthcare Medicaid	$24.61
Rate for Payer: UnitedHealthcare Medicare	$218.50
Rate for Payer: University Health Alliance Commercial	$318.53

29125-Short Arm

Facility

$389.00

Service Code	HCPCS 29125
Hospital Charge Code	8080072
Hospital Revenue Code	450
Min. Negotiated Rate	$194.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$194.50
Rate for Payer: Cash Price	$252.85
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	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$194.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$937.50
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 Medicare	$194.50
Rate for Payer: University Health Alliance Commercial	$283.54

29125-Short Arm

Facility

$389.00

Service Code	HCPCS 29125
Hospital Charge Code	8080072
Hospital Revenue Code	450
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

29126 Appl Forearm Splint Dynamc Bil

Facility

$760.00

Service Code	HCPCS 29126 50
Hospital Charge Code	8222627
Hospital Revenue Code	430
Min. Negotiated Rate	$646.00
Max. Negotiated Rate	$737.20
Rate for Payer: Cash Price	$494.00
Rate for Payer: Health Management Network Commercial	$646.00
Rate for Payer: Kaiser Permanente Commercial	$684.00
Rate for Payer: MDX Hawaii PPO	$737.20

29126 Appl Forearm Splint Dynamc Bil

Facility

$760.00

Service Code	HCPCS 29126 50
Hospital Charge Code	8222627
Hospital Revenue Code	430
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$737.20
Rate for Payer: AlohaCare Medicaid	$380.00
Rate for Payer: AlohaCare Medicare	$380.00
Rate for Payer: Cash Price	$494.00
Rate for Payer: Cash Price	$494.00
Rate for Payer: Devoted Health Medicare	$418.00
Rate for Payer: Hawaii Medical Service Association Medicare	$380.00
Rate for Payer: Hawaii Western Management Group Commercial	$722.00
Rate for Payer: Health Management Network Commercial	$646.00
Rate for Payer: Humana Medicare	$380.00
Rate for Payer: Kaiser Permanente Commercial	$684.00
Rate for Payer: Kaiser Permanente Medicaid	$387.60
Rate for Payer: Kaiser Permanente Medicare	$380.00
Rate for Payer: MDX Hawaii PPO	$737.20
Rate for Payer: Ohana Health Plan Medicaid	$380.00
Rate for Payer: Ohana Health Plan Medicare	$380.00
Rate for Payer: UnitedHealthcare Medicaid	$30.49
Rate for Payer: UnitedHealthcare Medicare	$380.00
Rate for Payer: University Health Alliance Commercial	$553.96

29126 Appl Forearm Splint Dynamic LT

Facility

$760.00

Service Code	HCPCS 29126 LT
Hospital Charge Code	8222628
Hospital Revenue Code	430
Min. Negotiated Rate	$646.00
Max. Negotiated Rate	$737.20
Rate for Payer: Cash Price	$494.00
Rate for Payer: Health Management Network Commercial	$646.00
Rate for Payer: Kaiser Permanente Commercial	$684.00
Rate for Payer: MDX Hawaii PPO	$737.20

29126 Appl Forearm Splint Dynamic LT

Facility

$760.00

Service Code	HCPCS 29126 LT
Hospital Charge Code	8222628
Hospital Revenue Code	430
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$737.20
Rate for Payer: AlohaCare Medicaid	$380.00
Rate for Payer: AlohaCare Medicare	$380.00
Rate for Payer: Cash Price	$494.00
Rate for Payer: Cash Price	$494.00
Rate for Payer: Devoted Health Medicare	$418.00
Rate for Payer: Hawaii Medical Service Association Medicare	$380.00
Rate for Payer: Hawaii Western Management Group Commercial	$722.00
Rate for Payer: Health Management Network Commercial	$646.00
Rate for Payer: Humana Medicare	$380.00
Rate for Payer: Kaiser Permanente Commercial	$684.00
Rate for Payer: Kaiser Permanente Medicaid	$387.60
Rate for Payer: Kaiser Permanente Medicare	$380.00
Rate for Payer: MDX Hawaii PPO	$737.20
Rate for Payer: Ohana Health Plan Medicaid	$380.00
Rate for Payer: Ohana Health Plan Medicare	$380.00
Rate for Payer: UnitedHealthcare Medicaid	$30.49
Rate for Payer: UnitedHealthcare Medicare	$380.00
Rate for Payer: University Health Alliance Commercial	$553.96

29126 Appl Forearm Splint Dynamic RT

Facility

$760.00

Service Code	HCPCS 29126 RT
Hospital Charge Code	8222629
Hospital Revenue Code	430
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$737.20
Rate for Payer: AlohaCare Medicaid	$380.00
Rate for Payer: AlohaCare Medicare	$380.00
Rate for Payer: Cash Price	$494.00
Rate for Payer: Cash Price	$494.00
Rate for Payer: Devoted Health Medicare	$418.00
Rate for Payer: Hawaii Medical Service Association Medicare	$380.00
Rate for Payer: Hawaii Western Management Group Commercial	$722.00
Rate for Payer: Health Management Network Commercial	$646.00
Rate for Payer: Humana Medicare	$380.00
Rate for Payer: Kaiser Permanente Commercial	$684.00
Rate for Payer: Kaiser Permanente Medicaid	$387.60
Rate for Payer: Kaiser Permanente Medicare	$380.00
Rate for Payer: MDX Hawaii PPO	$737.20
Rate for Payer: Ohana Health Plan Medicaid	$380.00
Rate for Payer: Ohana Health Plan Medicare	$380.00
Rate for Payer: UnitedHealthcare Medicaid	$30.49
Rate for Payer: UnitedHealthcare Medicare	$380.00
Rate for Payer: University Health Alliance Commercial	$553.96

29126 Appl Forearm Splint Dynamic RT

Facility

$760.00

Service Code	HCPCS 29126 RT
Hospital Charge Code	8222629
Hospital Revenue Code	430
Min. Negotiated Rate	$646.00
Max. Negotiated Rate	$737.20
Rate for Payer: Cash Price	$494.00
Rate for Payer: Health Management Network Commercial	$646.00
Rate for Payer: Kaiser Permanente Commercial	$684.00
Rate for Payer: MDX Hawaii PPO	$737.20

29126 Application of short arm splint (forearm to hand) dynamic

Professional

Both

$223.00

Service Code	HCPCS 29126
Hospital Charge Code	8038441
Hospital Revenue Code	975
Min. Negotiated Rate	$46.95
Max. Negotiated Rate	$189.55
Rate for Payer: AlohaCare Medicaid	$51.66
Rate for Payer: AlohaCare Medicare	$46.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Devoted Health Medicare	$51.65
Rate for Payer: Hawaii Medical Service Association ABD	$51.66
Rate for Payer: Hawaii Medical Service Association Commercial	$84.19
Rate for Payer: Hawaii Medical Service Association Medicare	$46.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.66
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$51.65
Rate for Payer: Kaiser Permanente Medicaid	$51.65
Rate for Payer: Kaiser Permanente Medicare	$51.65
Rate for Payer: Ohana Health Plan Medicaid	$51.66
Rate for Payer: Ohana Health Plan Medicare	$46.95
Rate for Payer: UnitedHealthcare Medicaid	$51.66
Rate for Payer: UnitedHealthcare Medicare	$46.95
Rate for Payer: University Health Alliance Commercial	$66.31

29130 Application Finger Splint LT

Facility

$641.00

Service Code	HCPCS 29130 LT
Hospital Charge Code	8222651
Hospital Revenue Code	430
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$416.65
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: MDX Hawaii PPO	$621.77

29130 Application Finger Splint LT

Facility

$641.00

Service Code	HCPCS 29130 LT
Hospital Charge Code	8222651
Hospital Revenue Code	430
Min. Negotiated Rate	$18.15
Max. Negotiated Rate	$621.77
Rate for Payer: AlohaCare Medicaid	$320.50
Rate for Payer: AlohaCare Medicare	$320.50
Rate for Payer: Cash Price	$416.65
Rate for Payer: Cash Price	$416.65
Rate for Payer: Devoted Health Medicare	$352.55
Rate for Payer: Hawaii Medical Service Association Medicare	$320.50
Rate for Payer: Hawaii Western Management Group Commercial	$608.95
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Humana Medicare	$320.50
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: Kaiser Permanente Medicare	$320.50
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: Ohana Health Plan Medicaid	$320.50
Rate for Payer: Ohana Health Plan Medicare	$320.50
Rate for Payer: UnitedHealthcare Medicaid	$18.15
Rate for Payer: UnitedHealthcare Medicare	$320.50
Rate for Payer: University Health Alliance Commercial	$467.22

29130 Application Finger Splint RT

Facility

$641.00

Service Code	HCPCS 29130 RT
Hospital Charge Code	8222652
Hospital Revenue Code	430
Min. Negotiated Rate	$18.15
Max. Negotiated Rate	$621.77
Rate for Payer: AlohaCare Medicaid	$320.50
Rate for Payer: AlohaCare Medicare	$320.50
Rate for Payer: Cash Price	$416.65
Rate for Payer: Cash Price	$416.65
Rate for Payer: Devoted Health Medicare	$352.55
Rate for Payer: Hawaii Medical Service Association Medicare	$320.50
Rate for Payer: Hawaii Western Management Group Commercial	$608.95
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Humana Medicare	$320.50
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: Kaiser Permanente Medicare	$320.50
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: Ohana Health Plan Medicaid	$320.50
Rate for Payer: Ohana Health Plan Medicare	$320.50
Rate for Payer: UnitedHealthcare Medicaid	$18.15
Rate for Payer: UnitedHealthcare Medicare	$320.50
Rate for Payer: University Health Alliance Commercial	$467.22

29130 Application Finger Splint RT

Facility

$641.00

Service Code	HCPCS 29130 RT
Hospital Charge Code	8222652
Hospital Revenue Code	430
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$416.65
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: MDX Hawaii PPO	$621.77

29130 APPLICATION FINGER SPLINT STATIC

Facility

$613.00

Service Code	HCPCS 29130
Hospital Charge Code	8023339
Hospital Revenue Code	450
Min. Negotiated Rate	$521.05
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$398.45
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Kaiser Permanente Commercial	$551.70
Rate for Payer: MDX Hawaii PPO	$594.61

29130 APPLICATION FINGER SPLINT STATIC

Facility

$613.00

Service Code	HCPCS 29130
Hospital Charge Code	8023339
Hospital Revenue Code	450
Min. Negotiated Rate	$306.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$306.50
Rate for Payer: Cash Price	$398.45
Rate for Payer: Cash Price	$398.45
Rate for Payer: Cash Price	$398.45
Rate for Payer: Devoted Health Medicare	$337.15
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$306.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$582.35
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Humana Medicare	$306.50
Rate for Payer: Kaiser Permanente Commercial	$551.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$306.50
Rate for Payer: MDX Hawaii PPO	$594.61
Rate for Payer: Ohana Health Plan Medicaid	$306.50
Rate for Payer: Ohana Health Plan Medicare	$306.50
Rate for Payer: UnitedHealthcare Medicare	$306.50
Rate for Payer: University Health Alliance Commercial	$446.82

29130 Apply Finger Splint Bilat

Facility

$641.00

Service Code	HCPCS 29130 50
Hospital Charge Code	8222654
Hospital Revenue Code	430
Min. Negotiated Rate	$18.15
Max. Negotiated Rate	$621.77
Rate for Payer: AlohaCare Medicaid	$320.50
Rate for Payer: AlohaCare Medicare	$320.50
Rate for Payer: Cash Price	$416.65
Rate for Payer: Cash Price	$416.65
Rate for Payer: Devoted Health Medicare	$352.55
Rate for Payer: Hawaii Medical Service Association Medicare	$320.50
Rate for Payer: Hawaii Western Management Group Commercial	$608.95
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Humana Medicare	$320.50
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: Kaiser Permanente Medicare	$320.50
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: Ohana Health Plan Medicaid	$320.50
Rate for Payer: Ohana Health Plan Medicare	$320.50
Rate for Payer: UnitedHealthcare Medicaid	$18.15
Rate for Payer: UnitedHealthcare Medicare	$320.50
Rate for Payer: University Health Alliance Commercial	$467.22

29130 Apply Finger Splint Bilat

Facility

$641.00

Service Code	HCPCS 29130 50
Hospital Charge Code	8222654
Hospital Revenue Code	430
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$416.65
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$576.90
Rate for Payer: MDX Hawaii PPO	$621.77

Know your out-of-pocket cost for care.

All Charges