Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Specific Gravity,Fluid FSI

Facility

$33.00

Service Code	HCPCS 84315
Hospital Charge Code	8404528
Hospital Revenue Code	301
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$16.50
Rate for Payer: AlohaCare Medicare	$16.50
Rate for Payer: Cash Price	$21.45
Rate for Payer: Cash Price	$21.45
Rate for Payer: Devoted Health Medicare	$18.15
Rate for Payer: Hawaii Medical Service Association ABD	$2.10
Rate for Payer: Hawaii Medical Service Association Commercial	$4.10
Rate for Payer: Hawaii Medical Service Association Medicare	$16.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.46
Rate for Payer: Hawaii Western Management Group Commercial	$3.28
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$16.50
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$16.50
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$16.50
Rate for Payer: Ohana Health Plan Medicare	$16.50
Rate for Payer: UnitedHealthcare Medicaid	$2.10
Rate for Payer: UnitedHealthcare Medicare	$16.50
Rate for Payer: University Health Alliance Commercial	$6.47

Specific Gravity,Fluid FSI

Facility

$33.00

Service Code	HCPCS 84315
Hospital Charge Code	8404528
Hospital Revenue Code	301
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$21.45
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$29.70
Rate for Payer: MDX Hawaii PPO	$32.01

Specific Gravity Urine††FSI

Facility

$37.00

Service Code	HCPCS 81003
Hospital Charge Code	8404427
Hospital Revenue Code	307
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

Specific Gravity Urine††FSI

Facility

$37.00

Service Code	HCPCS 81003
Hospital Charge Code	8404427
Hospital Revenue Code	307
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$18.50
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.35
Rate for Payer: Hawaii Medical Service Association ABD	$3.10
Rate for Payer: Hawaii Medical Service Association Commercial	$2.81
Rate for Payer: Hawaii Medical Service Association Medicare	$18.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.25
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$18.50
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$18.50
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$18.50
Rate for Payer: Ohana Health Plan Medicare	$18.50
Rate for Payer: UnitedHealthcare Medicaid	$3.10
Rate for Payer: UnitedHealthcare Medicare	$18.50
Rate for Payer: University Health Alliance Commercial	$5.81

Specimen Covid-19, Any Specimen Source-Drive Through

Facility

$81.00

Service Code	HCPCS C9803
Hospital Charge Code	8955809
Hospital Revenue Code	309
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$78.57
Rate for Payer: Cash Price	$52.65
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: MDX Hawaii PPO	$78.57

Specimen Covid-19, Any Specimen Source-Drive Through

Facility

$81.00

Service Code	HCPCS C9803
Hospital Charge Code	8955809
Hospital Revenue Code	309
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$78.57
Rate for Payer: AlohaCare Medicaid	$40.50
Rate for Payer: AlohaCare Medicare	$40.50
Rate for Payer: Cash Price	$52.65
Rate for Payer: Devoted Health Medicare	$44.55
Rate for Payer: Hawaii Medical Service Association Medicare	$40.50
Rate for Payer: Hawaii Western Management Group Commercial	$76.95
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Humana Medicare	$40.50
Rate for Payer: Kaiser Permanente Commercial	$72.90
Rate for Payer: Kaiser Permanente Medicaid	$41.31
Rate for Payer: Kaiser Permanente Medicare	$40.50
Rate for Payer: MDX Hawaii PPO	$78.57
Rate for Payer: Ohana Health Plan Medicaid	$40.50
Rate for Payer: Ohana Health Plan Medicare	$40.50
Rate for Payer: UnitedHealthcare Medicare	$40.50
Rate for Payer: University Health Alliance Commercial	$59.04

Specimen Covid-19, Any Specimen Source-ED Tech

Facility

$91.00

Service Code	HCPCS C9803
Hospital Charge Code	8955810
Hospital Revenue Code	300
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$59.15
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: MDX Hawaii PPO	$88.27

Specimen Covid-19, Any Specimen Source-ED Tech

Facility

$91.00

Service Code	HCPCS C9803
Hospital Charge Code	8955810
Hospital Revenue Code	300
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$45.50
Rate for Payer: AlohaCare Medicare	$45.50
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$50.05
Rate for Payer: Hawaii Medical Service Association Medicare	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$86.45
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$45.50
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$45.50
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$45.50
Rate for Payer: Ohana Health Plan Medicare	$45.50
Rate for Payer: UnitedHealthcare Medicare	$45.50
Rate for Payer: University Health Alliance Commercial	$66.33

Specimen to lab - Urinary Catheter Management:

Facility

$37.00

Service Code	HCPCS P9612
Hospital Charge Code	4607648
Hospital Revenue Code	300
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$18.50
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Devoted Health Medicare	$20.35
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$11.68
Rate for Payer: Hawaii Medical Service Association Medicare	$18.50
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$18.50
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$18.50
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$18.50
Rate for Payer: Ohana Health Plan Medicare	$18.50
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicare	$18.50
Rate for Payer: University Health Alliance Commercial	$26.97

Specimen to lab - Urinary Catheter Management:

Facility

$37.00

Service Code	HCPCS P9612
Hospital Charge Code	4607648
Hospital Revenue Code	300
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

Speech Fluency Eval Charge

Facility

$778.00

Service Code	HCPCS 92521 GO,CO
Hospital Charge Code	8169581
Hospital Revenue Code	444
Min. Negotiated Rate	$661.30
Max. Negotiated Rate	$754.66
Rate for Payer: Cash Price	$505.70
Rate for Payer: Health Management Network Commercial	$661.30
Rate for Payer: Kaiser Permanente Commercial	$700.20
Rate for Payer: MDX Hawaii PPO	$754.66

Speech Fluency Eval Charge

Facility

$778.00

Service Code	HCPCS 92521 GO,CO
Hospital Charge Code	8169581
Hospital Revenue Code	444
Min. Negotiated Rate	$140.32
Max. Negotiated Rate	$754.66
Rate for Payer: AlohaCare Medicaid	$389.00
Rate for Payer: AlohaCare Medicare	$389.00
Rate for Payer: Cash Price	$505.70
Rate for Payer: Cash Price	$505.70
Rate for Payer: Devoted Health Medicare	$427.90
Rate for Payer: Hawaii Medical Service Association Medicare	$389.00
Rate for Payer: Hawaii Western Management Group Commercial	$739.10
Rate for Payer: Health Management Network Commercial	$661.30
Rate for Payer: Humana Medicare	$389.00
Rate for Payer: Kaiser Permanente Commercial	$700.20
Rate for Payer: Kaiser Permanente Medicaid	$396.78
Rate for Payer: Kaiser Permanente Medicare	$389.00
Rate for Payer: MDX Hawaii PPO	$754.66
Rate for Payer: Ohana Health Plan Medicaid	$389.00
Rate for Payer: Ohana Health Plan Medicare	$389.00
Rate for Payer: UnitedHealthcare Medicaid	$140.32
Rate for Payer: UnitedHealthcare Medicare	$389.00
Rate for Payer: University Health Alliance Commercial	$567.08

Speech Generating Device Evaluation 1st hr Charge

Facility

$413.00

Service Code	HCPCS 92607 GO,CO
Hospital Charge Code	8171791
Hospital Revenue Code	444
Min. Negotiated Rate	$351.05
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$268.45
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: MDX Hawaii PPO	$400.61

Speech Generating Device Evaluation 1st hr Charge

Facility

$413.00

Service Code	HCPCS 92607 GO,CO
Hospital Charge Code	8171791
Hospital Revenue Code	444
Min. Negotiated Rate	$88.11
Max. Negotiated Rate	$400.61
Rate for Payer: AlohaCare Medicaid	$206.50
Rate for Payer: AlohaCare Medicare	$206.50
Rate for Payer: Cash Price	$268.45
Rate for Payer: Cash Price	$268.45
Rate for Payer: Devoted Health Medicare	$227.15
Rate for Payer: Hawaii Medical Service Association Medicare	$206.50
Rate for Payer: Hawaii Western Management Group Commercial	$392.35
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Humana Medicare	$206.50
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: Kaiser Permanente Medicaid	$210.63
Rate for Payer: Kaiser Permanente Medicare	$206.50
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: Ohana Health Plan Medicaid	$206.50
Rate for Payer: Ohana Health Plan Medicare	$206.50
Rate for Payer: UnitedHealthcare Medicaid	$88.11
Rate for Payer: UnitedHealthcare Medicare	$206.50
Rate for Payer: University Health Alliance Commercial	$301.04

Speech Generating Device Service Charge

Facility

$227.00

Service Code	HCPCS 92608 GO,CO
Hospital Charge Code	8177112
Hospital Revenue Code	444
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$147.55
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: MDX Hawaii PPO	$220.19

Speech Generating Device Service Charge

Facility

$227.00

Service Code	HCPCS 92608 GO,CO
Hospital Charge Code	8177112
Hospital Revenue Code	444
Min. Negotiated Rate	$17.26
Max. Negotiated Rate	$220.19
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$113.50
Rate for Payer: Cash Price	$147.55
Rate for Payer: Cash Price	$147.55
Rate for Payer: Devoted Health Medicare	$124.85
Rate for Payer: Hawaii Medical Service Association Medicare	$113.50
Rate for Payer: Hawaii Western Management Group Commercial	$215.65
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Humana Medicare	$113.50
Rate for Payer: Kaiser Permanente Commercial	$204.30
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: Kaiser Permanente Medicare	$113.50
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: Ohana Health Plan Medicaid	$113.50
Rate for Payer: Ohana Health Plan Medicare	$113.50
Rate for Payer: UnitedHealthcare Medicaid	$17.26
Rate for Payer: UnitedHealthcare Medicare	$113.50
Rate for Payer: University Health Alliance Commercial	$165.46

Speech Sound Production Eval Charge

Facility

$665.00

Service Code	HCPCS 92522 GP,59
Hospital Charge Code	8169587
Hospital Revenue Code	444
Min. Negotiated Rate	$116.85
Max. Negotiated Rate	$645.05
Rate for Payer: AlohaCare Medicaid	$332.50
Rate for Payer: AlohaCare Medicare	$332.50
Rate for Payer: Cash Price	$432.25
Rate for Payer: Cash Price	$432.25
Rate for Payer: Devoted Health Medicare	$365.75
Rate for Payer: Hawaii Medical Service Association Medicare	$332.50
Rate for Payer: Hawaii Western Management Group Commercial	$631.75
Rate for Payer: Health Management Network Commercial	$565.25
Rate for Payer: Humana Medicare	$332.50
Rate for Payer: Kaiser Permanente Commercial	$598.50
Rate for Payer: Kaiser Permanente Medicaid	$339.15
Rate for Payer: Kaiser Permanente Medicare	$332.50
Rate for Payer: MDX Hawaii PPO	$645.05
Rate for Payer: Ohana Health Plan Medicaid	$332.50
Rate for Payer: Ohana Health Plan Medicare	$332.50
Rate for Payer: UnitedHealthcare Medicaid	$116.85
Rate for Payer: UnitedHealthcare Medicare	$332.50
Rate for Payer: University Health Alliance Commercial	$484.72

Speech Sound Production Eval Charge

Facility

$665.00

Service Code	HCPCS 92522 GP,59
Hospital Charge Code	8169587
Hospital Revenue Code	444
Min. Negotiated Rate	$565.25
Max. Negotiated Rate	$645.05
Rate for Payer: Cash Price	$432.25
Rate for Payer: Health Management Network Commercial	$565.25
Rate for Payer: Kaiser Permanente Commercial	$598.50
Rate for Payer: MDX Hawaii PPO	$645.05

Speech Sound Prod w/ Language Charge

Facility

$572.00

Service Code	HCPCS 92523 GO,CO
Hospital Charge Code	8170124
Hospital Revenue Code	444
Min. Negotiated Rate	$486.20
Max. Negotiated Rate	$554.84
Rate for Payer: Cash Price	$371.80
Rate for Payer: Health Management Network Commercial	$486.20
Rate for Payer: Kaiser Permanente Commercial	$514.80
Rate for Payer: MDX Hawaii PPO	$554.84

Speech Sound Prod w/ Language Charge

Facility

$572.00

Service Code	HCPCS 92523 GO,CO
Hospital Charge Code	8170124
Hospital Revenue Code	444
Min. Negotiated Rate	$240.61
Max. Negotiated Rate	$554.84
Rate for Payer: AlohaCare Medicaid	$286.00
Rate for Payer: AlohaCare Medicare	$286.00
Rate for Payer: Cash Price	$371.80
Rate for Payer: Cash Price	$371.80
Rate for Payer: Devoted Health Medicare	$314.60
Rate for Payer: Hawaii Medical Service Association Medicare	$286.00
Rate for Payer: Hawaii Western Management Group Commercial	$543.40
Rate for Payer: Health Management Network Commercial	$486.20
Rate for Payer: Humana Medicare	$286.00
Rate for Payer: Kaiser Permanente Commercial	$514.80
Rate for Payer: Kaiser Permanente Medicaid	$291.72
Rate for Payer: Kaiser Permanente Medicare	$286.00
Rate for Payer: MDX Hawaii PPO	$554.84
Rate for Payer: Ohana Health Plan Medicaid	$286.00
Rate for Payer: Ohana Health Plan Medicare	$286.00
Rate for Payer: UnitedHealthcare Medicaid	$240.61
Rate for Payer: UnitedHealthcare Medicare	$286.00
Rate for Payer: University Health Alliance Commercial	$416.93

Speech Sound Prod w/ Language Charge

Facility

$572.00

Service Code	HCPCS 92523 GP,59
Hospital Charge Code	8177184
Hospital Revenue Code	444
Min. Negotiated Rate	$486.20
Max. Negotiated Rate	$554.84
Rate for Payer: Cash Price	$371.80
Rate for Payer: Health Management Network Commercial	$486.20
Rate for Payer: Kaiser Permanente Commercial	$514.80
Rate for Payer: MDX Hawaii PPO	$554.84

Speech Sound Prod w/ Language Charge

Facility

$572.00

Service Code	HCPCS 92523 GP,59
Hospital Charge Code	8177184
Hospital Revenue Code	444
Min. Negotiated Rate	$240.61
Max. Negotiated Rate	$554.84
Rate for Payer: AlohaCare Medicaid	$286.00
Rate for Payer: AlohaCare Medicare	$286.00
Rate for Payer: Cash Price	$371.80
Rate for Payer: Cash Price	$371.80
Rate for Payer: Devoted Health Medicare	$314.60
Rate for Payer: Hawaii Medical Service Association Medicare	$286.00
Rate for Payer: Hawaii Western Management Group Commercial	$543.40
Rate for Payer: Health Management Network Commercial	$486.20
Rate for Payer: Humana Medicare	$286.00
Rate for Payer: Kaiser Permanente Commercial	$514.80
Rate for Payer: Kaiser Permanente Medicaid	$291.72
Rate for Payer: Kaiser Permanente Medicare	$286.00
Rate for Payer: MDX Hawaii PPO	$554.84
Rate for Payer: Ohana Health Plan Medicaid	$286.00
Rate for Payer: Ohana Health Plan Medicare	$286.00
Rate for Payer: UnitedHealthcare Medicaid	$240.61
Rate for Payer: UnitedHealthcare Medicare	$286.00
Rate for Payer: University Health Alliance Commercial	$416.93

Sperm, Post Vasectomy FSI

Facility

$105.00

Service Code	HCPCS 89300
Hospital Charge Code	8118048
Hospital Revenue Code	309
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$101.85
Rate for Payer: AlohaCare Medicaid	$52.50
Rate for Payer: AlohaCare Medicare	$52.50
Rate for Payer: Cash Price	$68.25
Rate for Payer: Cash Price	$68.25
Rate for Payer: Devoted Health Medicare	$57.75
Rate for Payer: Hawaii Medical Service Association ABD	$12.32
Rate for Payer: Hawaii Medical Service Association Commercial	$12.30
Rate for Payer: Hawaii Medical Service Association Medicare	$52.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.94
Rate for Payer: Hawaii Western Management Group Commercial	$9.84
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Humana Medicare	$52.50
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$53.55
Rate for Payer: Kaiser Permanente Medicare	$52.50
Rate for Payer: MDX Hawaii PPO	$101.85
Rate for Payer: Ohana Health Plan Medicaid	$52.50
Rate for Payer: Ohana Health Plan Medicare	$52.50
Rate for Payer: UnitedHealthcare Medicaid	$12.32
Rate for Payer: UnitedHealthcare Medicare	$52.50
Rate for Payer: University Health Alliance Commercial	$23.03

Sperm, Post Vasectomy FSI

Facility

$105.00

Service Code	HCPCS 89300
Hospital Charge Code	8118048
Hospital Revenue Code	309
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$101.85
Rate for Payer: Cash Price	$68.25
Rate for Payer: Health Management Network Commercial	$89.25
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: MDX Hawaii PPO	$101.85

SPINAL DISORDERS AND INJURIES WITH CC/MCC

Facility

$37,198.66

Service Code	MSDRG 052
Min. Negotiated Rate	$37,198.66
Max. Negotiated Rate	$37,198.66
Rate for Payer: Hawaii Medical Service Association Commercial	$37,198.66

Know your out-of-pocket cost for care.

All Charges