Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

OT Cog Ther Intervent, Addl 15 Min Asst

Facility

$149.00

Service Code	HCPCS 97130 GO,CO
Hospital Charge Code	8740074
Hospital Revenue Code	430
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

OT Cog Ther Intervent, Addl 15 Min Units

Facility

$149.00

Service Code	HCPCS 97130 GP,CQ
Hospital Charge Code	8740072
Hospital Revenue Code	430
Min. Negotiated Rate	$21.52
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 Medicare	$74.50
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
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	$21.52
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$108.61

OT Cog Ther Intervent, Addl 15 Min Units

Facility

$149.00

Service Code	HCPCS 97130 GP,CQ
Hospital Charge Code	8740072
Hospital Revenue Code	430
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

OT Cog Ther Intervent, First 15 Min Asst

Facility

$152.00

Service Code	HCPCS 97129 GO,CO
Hospital Charge Code	8740068
Hospital Revenue Code	430
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$147.44
Rate for Payer: AlohaCare Medicaid	$76.00
Rate for Payer: AlohaCare Medicare	$76.00
Rate for Payer: Cash Price	$98.80
Rate for Payer: Cash Price	$98.80
Rate for Payer: Devoted Health Medicare	$83.60
Rate for Payer: Hawaii Medical Service Association Medicare	$76.00
Rate for Payer: Hawaii Western Management Group Commercial	$144.40
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Humana Medicare	$76.00
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicare	$76.00
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: Ohana Health Plan Medicaid	$76.00
Rate for Payer: Ohana Health Plan Medicare	$76.00
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: UnitedHealthcare Medicare	$76.00
Rate for Payer: University Health Alliance Commercial	$110.79

OT Cog Ther Intervent, First 15 Min Asst

Facility

$152.00

Service Code	HCPCS 97129 GO,CO
Hospital Charge Code	8740067
Hospital Revenue Code	430
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$147.44
Rate for Payer: AlohaCare Medicaid	$76.00
Rate for Payer: AlohaCare Medicare	$76.00
Rate for Payer: Cash Price	$98.80
Rate for Payer: Cash Price	$98.80
Rate for Payer: Devoted Health Medicare	$83.60
Rate for Payer: Hawaii Medical Service Association Medicare	$76.00
Rate for Payer: Hawaii Western Management Group Commercial	$144.40
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Humana Medicare	$76.00
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicare	$76.00
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: Ohana Health Plan Medicaid	$76.00
Rate for Payer: Ohana Health Plan Medicare	$76.00
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: UnitedHealthcare Medicare	$76.00
Rate for Payer: University Health Alliance Commercial	$110.79

OT Cog Ther Intervent, First 15 Min Asst

Facility

$152.00

Service Code	HCPCS 97129 GO,CO
Hospital Charge Code	8740068
Hospital Revenue Code	430
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

OT Cog Ther Intervent, First 15 Min Asst

Facility

$152.00

Service Code	HCPCS 97129 GO,CO
Hospital Charge Code	8740067
Hospital Revenue Code	430
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

OT Cog Ther Intervent,First 15 Min Units

Facility

$152.00

Service Code	HCPCS 97129 GP,CQ
Hospital Charge Code	8740066
Hospital Revenue Code	430
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$147.44
Rate for Payer: AlohaCare Medicaid	$76.00
Rate for Payer: AlohaCare Medicare	$76.00
Rate for Payer: Cash Price	$98.80
Rate for Payer: Cash Price	$98.80
Rate for Payer: Devoted Health Medicare	$83.60
Rate for Payer: Hawaii Medical Service Association Medicare	$76.00
Rate for Payer: Hawaii Western Management Group Commercial	$144.40
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Humana Medicare	$76.00
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicare	$76.00
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: Ohana Health Plan Medicaid	$76.00
Rate for Payer: Ohana Health Plan Medicare	$76.00
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: UnitedHealthcare Medicare	$76.00
Rate for Payer: University Health Alliance Commercial	$110.79

OT Cog Ther Intervent,First 15 Min Units

Facility

$152.00

Service Code	HCPCS 97129 GP,CQ
Hospital Charge Code	8740066
Hospital Revenue Code	430
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

OT Comm,Work Reintegration Assist Units

Facility

$251.00

Service Code	HCPCS 97537 GO,CO
Hospital Charge Code	8725614
Hospital Revenue Code	430
Min. Negotiated Rate	$18.95
Max. Negotiated Rate	$243.47
Rate for Payer: AlohaCare Medicaid	$125.50
Rate for Payer: AlohaCare Medicare	$125.50
Rate for Payer: Cash Price	$163.15
Rate for Payer: Cash Price	$163.15
Rate for Payer: Devoted Health Medicare	$138.05
Rate for Payer: Hawaii Medical Service Association Medicare	$125.50
Rate for Payer: Hawaii Western Management Group Commercial	$238.45
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Humana Medicare	$125.50
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: Kaiser Permanente Medicaid	$128.01
Rate for Payer: Kaiser Permanente Medicare	$125.50
Rate for Payer: MDX Hawaii PPO	$243.47
Rate for Payer: Ohana Health Plan Medicaid	$125.50
Rate for Payer: Ohana Health Plan Medicare	$125.50
Rate for Payer: UnitedHealthcare Medicaid	$18.95
Rate for Payer: UnitedHealthcare Medicare	$125.50
Rate for Payer: University Health Alliance Commercial	$182.95

OT Comm,Work Reintegration Assist Units

Facility

$251.00

Service Code	HCPCS 97537 GO,CO
Hospital Charge Code	8725614
Hospital Revenue Code	430
Min. Negotiated Rate	$213.35
Max. Negotiated Rate	$243.47
Rate for Payer: Cash Price	$163.15
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: MDX Hawaii PPO	$243.47

OT Contrast Bath Assistant Units

Facility

$101.00

Service Code	HCPCS 97034 GO,CO
Hospital Charge Code	8720929
Hospital Revenue Code	430
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$11.39
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$73.62

OT Contrast Bath Assistant Units

Facility

$101.00

Service Code	HCPCS 97034 GO,CO
Hospital Charge Code	8720929
Hospital Revenue Code	430
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

OT Contrast Bath Charges

Facility

$101.00

Service Code	HCPCS 97034 RT,26
Hospital Charge Code	8123872
Hospital Revenue Code	430
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$11.39
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$73.62

OT Contrast Bath Charges

Facility

$101.00

Service Code	HCPCS 97034 RT,26
Hospital Charge Code	8123872
Hospital Revenue Code	430
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

OT Daily Note Swingbed

Facility

$155.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	8200982
Hospital Revenue Code	430
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

OT Daily Note Swingbed

Facility

$155.00

Service Code	HCPCS 97129 GO
Hospital Charge Code	8200982
Hospital Revenue Code	430
Min. Negotiated Rate	$22.57
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$77.50
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Devoted Health Medicare	$85.25
Rate for Payer: Hawaii Medical Service Association Medicare	$77.50
Rate for Payer: Hawaii Western Management Group Commercial	$147.25
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$77.50
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$77.50
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$77.50
Rate for Payer: Ohana Health Plan Medicare	$77.50
Rate for Payer: UnitedHealthcare Medicaid	$22.57
Rate for Payer: UnitedHealthcare Medicare	$77.50
Rate for Payer: University Health Alliance Commercial	$112.98

OTElectrical Stim (Unattended) - Non-Wound

Facility

$100.00

Service Code	HCPCS 97014 GO
Hospital Charge Code	1373552
Hospital Revenue Code	430
Min. Negotiated Rate	$11.85
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 Medicare	$50.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.00
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	$11.85
Rate for Payer: UnitedHealthcare Medicare	$50.00
Rate for Payer: University Health Alliance Commercial	$72.89

OTElectrical Stim (Unattended) - Non-Wound

Facility

$100.00

Service Code	HCPCS 97014 GO
Hospital Charge Code	1373552
Hospital Revenue Code	430
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

OT Group Therapy Assistant Units

Facility

$132.00

Service Code	HCPCS 97150 GO,CO
Hospital Charge Code	8720917
Hospital Revenue Code	430
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

OT Group Therapy Assistant Units

Facility

$132.00

Service Code	HCPCS 97150 GO,CO
Hospital Charge Code	8720917
Hospital Revenue Code	430
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$96.21

OT Group Therapy Units

Facility

$132.00

Service Code	HCPCS 97150 RT,26
Hospital Charge Code	1373451
Hospital Revenue Code	430
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

OT Group Therapy Units

Facility

$132.00

Service Code	HCPCS 97150 RT,26
Hospital Charge Code	1373451
Hospital Revenue Code	430
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$96.21

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC

Facility

$11,422.21

Service Code	MSDRG 818
Min. Negotiated Rate	$11,422.21
Max. Negotiated Rate	$11,422.21
Rate for Payer: Hawaii Medical Service Association Commercial	$11,422.21

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC

Facility

$11,422.21

Service Code	MSDRG 817
Min. Negotiated Rate	$11,422.21
Max. Negotiated Rate	$11,422.21
Rate for Payer: Hawaii Medical Service Association Commercial	$11,422.21

Know your out-of-pocket cost for care.

All Charges