Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PT Unattended E-Stim Assistant Units

Facility

$100.00

Service Code	HCPCS 97014 GP,CO
Hospital Charge Code	8720394
Hospital Revenue Code	420
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$97.00
Rate for Payer: MDX Hawaii PPO	$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: 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

PT Unattended E-Stim Units

Facility

$100.00

Service Code	HCPCS 97014 GP,CQ
Hospital Charge Code	1374022
Hospital Revenue Code	420
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

PT Unattended E-Stim Units

Facility

$100.00

Service Code	HCPCS 97014 GP,CQ
Hospital Charge Code	1374022
Hospital Revenue Code	420
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

PT Unlisted PHYS MED/REHAB Assit Unit

Facility

$114.00

Service Code	HCPCS 97799 GP,CQ
Hospital Charge Code	8734679
Hospital Revenue Code	420
Min. Negotiated Rate	$57.00
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$62.70
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$83.09

PT Unlisted PHYS MED/REHAB Assit Unit

Facility

$114.00

Service Code	HCPCS 97799 GP,CQ
Hospital Charge Code	8734679
Hospital Revenue Code	420
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

PT Unlisted Therapeutic Procedures Charges

Facility

$114.00

Service Code	HCPCS 97139 GP,CQ
Hospital Charge Code	8111831
Hospital Revenue Code	420
Min. Negotiated Rate	$12.02
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$62.70
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$12.02
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$83.09

PT Unlisted Therapeutic Procedures Charges

Facility

$114.00

Service Code	HCPCS 97139 GP,CQ
Hospital Charge Code	8111831
Hospital Revenue Code	420
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

PT Unlisted Ther Procedure Assit Units

Facility

$114.00

Service Code	HCPCS 97139 GP,CQ
Hospital Charge Code	8733303
Hospital Revenue Code	420
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

PT Unlisted Ther Procedure Assit Units

Facility

$114.00

Service Code	HCPCS 97139 GP,CQ
Hospital Charge Code	8733303
Hospital Revenue Code	420
Min. Negotiated Rate	$12.02
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$62.70
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$12.02
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$83.09

PT Vasopneumatic Devices Assistant Units

Facility

$92.00

Service Code	HCPCS 97016 GP,CQ
Hospital Charge Code	8720396
Hospital Revenue Code	420
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

PT Vasopneumatic Devices Assistant Units

Facility

$92.00

Service Code	HCPCS 97016 GP,CQ
Hospital Charge Code	8720396
Hospital Revenue Code	420
Min. Negotiated Rate	$12.49
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: 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 Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$67.06

PT Vasopneumatic Devices Units

Facility

$92.00

Service Code	HCPCS 97016 GP,CQ
Hospital Charge Code	1374023
Hospital Revenue Code	420
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

PT Vasopneumatic Devices Units

Facility

$92.00

Service Code	HCPCS 97016 GP,CQ
Hospital Charge Code	1374023
Hospital Revenue Code	420
Min. Negotiated Rate	$12.49
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: 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 Medicaid	$12.49
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$67.06

PT Wheelchair management Assistant Units

Facility

$257.00

Service Code	HCPCS 97542 GP,CQ
Hospital Charge Code	8720454
Hospital Revenue Code	420
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

PT Wheelchair management Assistant Units

Facility

$257.00

Service Code	HCPCS 97542 GP,CQ
Hospital Charge Code	8720454
Hospital Revenue Code	420
Min. Negotiated Rate	$17.54
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicaid	$17.54
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$187.33

PT Whirlpool, Fluidotherapy Assist Units

Facility

$126.00

Service Code	HCPCS 97022 GP,CQ
Hospital Charge Code	8720400
Hospital Revenue Code	420
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$119.70
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$91.84

PT Whirlpool, Fluidotherapy Assist Units

Facility

$126.00

Service Code	HCPCS 97022 GP,CQ
Hospital Charge Code	8720400
Hospital Revenue Code	420
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

PT Wound Vac <50 Assist Units

Facility

$1,233.00

Service Code	HCPCS 97607 GP,CQ
Hospital Charge Code	8736350
Hospital Revenue Code	420
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

PT Wound Vac <50 Assist Units

Facility

$1,233.00

Service Code	HCPCS 97607 GP,CQ
Hospital Charge Code	8736350
Hospital Revenue Code	420
Min. Negotiated Rate	$20.89
Max. Negotiated Rate	$1,196.01
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$616.50
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$678.15
Rate for Payer: Hawaii Medical Service Association Medicare	$616.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$616.50
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$628.83
Rate for Payer: Kaiser Permanente Medicare	$616.50
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$616.50
Rate for Payer: Ohana Health Plan Medicare	$616.50
Rate for Payer: UnitedHealthcare Medicaid	$20.89
Rate for Payer: UnitedHealthcare Medicare	$616.50
Rate for Payer: University Health Alliance Commercial	$898.73

PT Wound Vac >50 Assist Units

Facility

$1,233.00

Service Code	HCPCS 97608 GP,CQ
Hospital Charge Code	8736355
Hospital Revenue Code	420
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

PT Wound Vac >50 Assist Units

Facility

$1,233.00

Service Code	HCPCS 97608 GP,CQ
Hospital Charge Code	8736355
Hospital Revenue Code	420
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$1,196.01
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$616.50
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$678.15
Rate for Payer: Hawaii Medical Service Association Medicare	$616.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$616.50
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$628.83
Rate for Payer: Kaiser Permanente Medicare	$616.50
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$616.50
Rate for Payer: Ohana Health Plan Medicare	$616.50
Rate for Payer: UnitedHealthcare Medicaid	$24.26
Rate for Payer: UnitedHealthcare Medicare	$616.50
Rate for Payer: University Health Alliance Commercial	$898.73

PT Wound VAC <50 Charge

Facility

$1,541.00

Service Code	HCPCS 97607 LT,26
Hospital Charge Code	8111766
Hospital Revenue Code	420
Min. Negotiated Rate	$1,309.85
Max. Negotiated Rate	$1,494.77
Rate for Payer: Cash Price	$1,001.65
Rate for Payer: Health Management Network Commercial	$1,309.85
Rate for Payer: Kaiser Permanente Commercial	$1,386.90
Rate for Payer: MDX Hawaii PPO	$1,494.77

PT Wound VAC <50 Charge

Facility

$1,541.00

Service Code	HCPCS 97607 LT,26
Hospital Charge Code	8111766
Hospital Revenue Code	420
Min. Negotiated Rate	$20.89
Max. Negotiated Rate	$1,494.77
Rate for Payer: AlohaCare Medicaid	$770.50
Rate for Payer: AlohaCare Medicare	$770.50
Rate for Payer: Cash Price	$1,001.65
Rate for Payer: Cash Price	$1,001.65
Rate for Payer: Devoted Health Medicare	$847.55
Rate for Payer: Hawaii Medical Service Association Medicare	$770.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,463.95
Rate for Payer: Health Management Network Commercial	$1,309.85
Rate for Payer: Humana Medicare	$770.50
Rate for Payer: Kaiser Permanente Commercial	$1,386.90
Rate for Payer: Kaiser Permanente Medicaid	$785.91
Rate for Payer: Kaiser Permanente Medicare	$770.50
Rate for Payer: MDX Hawaii PPO	$1,494.77
Rate for Payer: Ohana Health Plan Medicaid	$770.50
Rate for Payer: Ohana Health Plan Medicare	$770.50
Rate for Payer: UnitedHealthcare Medicaid	$20.89
Rate for Payer: UnitedHealthcare Medicare	$770.50
Rate for Payer: University Health Alliance Commercial	$1,123.23

PT Wound VAC >50 Charge

Facility

$1,541.00

Service Code	HCPCS 97608 RT,26
Hospital Charge Code	8111797
Hospital Revenue Code	420
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$1,494.77
Rate for Payer: AlohaCare Medicaid	$770.50
Rate for Payer: AlohaCare Medicare	$770.50
Rate for Payer: Cash Price	$1,001.65
Rate for Payer: Cash Price	$1,001.65
Rate for Payer: Devoted Health Medicare	$847.55
Rate for Payer: Hawaii Medical Service Association Medicare	$770.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,463.95
Rate for Payer: Health Management Network Commercial	$1,309.85
Rate for Payer: Humana Medicare	$770.50
Rate for Payer: Kaiser Permanente Commercial	$1,386.90
Rate for Payer: Kaiser Permanente Medicaid	$785.91
Rate for Payer: Kaiser Permanente Medicare	$770.50
Rate for Payer: MDX Hawaii PPO	$1,494.77
Rate for Payer: Ohana Health Plan Medicaid	$770.50
Rate for Payer: Ohana Health Plan Medicare	$770.50
Rate for Payer: UnitedHealthcare Medicaid	$24.26
Rate for Payer: UnitedHealthcare Medicare	$770.50
Rate for Payer: University Health Alliance Commercial	$1,123.23

PT Wound VAC >50 Charge

Facility

$1,541.00

Service Code	HCPCS 97608 RT,26
Hospital Charge Code	8111797
Hospital Revenue Code	420
Min. Negotiated Rate	$1,309.85
Max. Negotiated Rate	$1,494.77
Rate for Payer: Cash Price	$1,001.65
Rate for Payer: Health Management Network Commercial	$1,309.85
Rate for Payer: Kaiser Permanente Commercial	$1,386.90
Rate for Payer: MDX Hawaii PPO	$1,494.77

Know your out-of-pocket cost for care.

All Charges