Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Work Reconditioning Additional Hours Charge

Facility

$102.00

Service Code	HCPCS 97546 GO
Hospital Charge Code	8123851
Hospital Revenue Code	430
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$98.94
Rate for Payer: AlohaCare Medicaid	$51.00
Rate for Payer: AlohaCare Medicare	$51.00
Rate for Payer: Cash Price	$66.30
Rate for Payer: Devoted Health Medicare	$56.10
Rate for Payer: Hawaii Medical Service Association Medicare	$51.00
Rate for Payer: Hawaii Western Management Group Commercial	$96.90
Rate for Payer: Health Management Network Commercial	$86.70
Rate for Payer: Humana Medicare	$51.00
Rate for Payer: Kaiser Permanente Commercial	$91.80
Rate for Payer: Kaiser Permanente Medicaid	$52.02
Rate for Payer: Kaiser Permanente Medicare	$51.00
Rate for Payer: MDX Hawaii PPO	$98.94
Rate for Payer: Ohana Health Plan Medicaid	$51.00
Rate for Payer: Ohana Health Plan Medicare	$51.00
Rate for Payer: UnitedHealthcare Medicare	$51.00
Rate for Payer: University Health Alliance Commercial	$74.35

Work Reconditioning Charge

Facility

$307.00

Service Code	HCPCS 97545 GO
Hospital Charge Code	8123850
Hospital Revenue Code	430
Min. Negotiated Rate	$260.95
Max. Negotiated Rate	$297.79
Rate for Payer: Cash Price	$199.55
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: MDX Hawaii PPO	$297.79

Work Reconditioning Charge

Facility

$307.00

Service Code	HCPCS 97545 GO
Hospital Charge Code	8123850
Hospital Revenue Code	430
Min. Negotiated Rate	$153.50
Max. Negotiated Rate	$297.79
Rate for Payer: AlohaCare Medicaid	$153.50
Rate for Payer: AlohaCare Medicare	$153.50
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$168.85
Rate for Payer: Hawaii Medical Service Association Medicare	$153.50
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Humana Medicare	$153.50
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: Kaiser Permanente Medicare	$153.50
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: Ohana Health Plan Medicaid	$153.50
Rate for Payer: Ohana Health Plan Medicare	$153.50
Rate for Payer: UnitedHealthcare Medicare	$153.50
Rate for Payer: University Health Alliance Commercial	$223.77

Wound Culture Aerobic, Anaerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118088
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$22.26

Wound Culture Aerobic, Anaerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118088
Hospital Revenue Code	306
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Wound Culture Aerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118087
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$22.26

Wound Culture Aerobic FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8118087
Hospital Revenue Code	306
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$108,791.43

Service Code	MSDRG 464
Min. Negotiated Rate	$108,791.43
Max. Negotiated Rate	$108,791.43
Rate for Payer: Hawaii Medical Service Association Commercial	$108,791.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$108,791.43

Service Code	MSDRG 463
Min. Negotiated Rate	$108,791.43
Max. Negotiated Rate	$108,791.43
Rate for Payer: Hawaii Medical Service Association Commercial	$108,791.43

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$108,791.43

Service Code	MSDRG 465
Min. Negotiated Rate	$108,791.43
Max. Negotiated Rate	$108,791.43
Rate for Payer: Hawaii Medical Service Association Commercial	$108,791.43

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$30,212.76

Service Code	MSDRG 902
Min. Negotiated Rate	$30,212.76
Max. Negotiated Rate	$30,212.76
Rate for Payer: Hawaii Medical Service Association Commercial	$30,212.76

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$30,212.76

Service Code	MSDRG 901
Min. Negotiated Rate	$30,212.76
Max. Negotiated Rate	$30,212.76
Rate for Payer: Hawaii Medical Service Association Commercial	$30,212.76

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$30,212.76

Service Code	MSDRG 903
Min. Negotiated Rate	$30,212.76
Max. Negotiated Rate	$30,212.76
Rate for Payer: Hawaii Medical Service Association Commercial	$30,212.76

Wright's Stain FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228945
Hospital Revenue Code	306
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Wright's Stain FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228945
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$11.03

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369812
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369812
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369798
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; L R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369798
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369805
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369805
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369799
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; M R)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369799
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; S L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369800
Hospital Revenue Code	274
Min. Negotiated Rate	$107.29
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$324.80

Wrist Hand finger Orthosis, w/o joint, prefab, customized (resting hand; S L)

Facility

$580.00

Service Code	HCPCS L3807
Hospital Charge Code	13369800
Hospital Revenue Code	274
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: University Health Alliance Commercial	$324.80

Know your out-of-pocket cost for care.

All Charges