Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

86361

Facility

$29.00

Service Code	HCPCS 86361
Hospital Charge Code	13395368
Hospital Revenue Code	300
Min. Negotiated Rate	$14.50
Max. Negotiated Rate	$46.77
Rate for Payer: AlohaCare Medicaid	$14.50
Rate for Payer: AlohaCare Medicare	$14.50
Rate for Payer: Cash Price	$18.85
Rate for Payer: Cash Price	$18.85
Rate for Payer: Devoted Health Medicare	$15.95
Rate for Payer: Hawaii Medical Service Association ABD	$25.00
Rate for Payer: Hawaii Medical Service Association Commercial	$33.48
Rate for Payer: Hawaii Medical Service Association Medicare	$14.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.25
Rate for Payer: Hawaii Western Management Group Commercial	$26.78
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Humana Medicare	$14.50
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: Kaiser Permanente Medicare	$14.50
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: Ohana Health Plan Medicaid	$14.50
Rate for Payer: Ohana Health Plan Medicare	$14.50
Rate for Payer: UnitedHealthcare Medicaid	$25.00
Rate for Payer: UnitedHealthcare Medicare	$14.50
Rate for Payer: University Health Alliance Commercial	$46.77

86361

Facility

$29.00

Service Code	HCPCS 86361
Hospital Charge Code	13395368
Hospital Revenue Code	300
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$18.85
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: MDX Hawaii PPO	$28.13

86615 Bordetella Ab SO

Facility

$148.00

Service Code	HCPCS 86615
Hospital Charge Code	9916626
Hospital Revenue Code	302
Min. Negotiated Rate	$125.80
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$96.20
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Kaiser Permanente Commercial	$133.20
Rate for Payer: MDX Hawaii PPO	$143.56

86615 Bordetella Ab SO

Facility

$148.00

Service Code	HCPCS 86615
Hospital Charge Code	9916626
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$143.56
Rate for Payer: AlohaCare Medicaid	$74.00
Rate for Payer: AlohaCare Medicare	$74.00
Rate for Payer: Cash Price	$96.20
Rate for Payer: Cash Price	$96.20
Rate for Payer: Devoted Health Medicare	$81.40
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$74.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Humana Medicare	$74.00
Rate for Payer: Kaiser Permanente Commercial	$133.20
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: Kaiser Permanente Medicare	$74.00
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: Ohana Health Plan Medicaid	$74.00
Rate for Payer: Ohana Health Plan Medicare	$74.00
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$74.00
Rate for Payer: University Health Alliance Commercial	$34.10

86880 - Cord Blood Workup

Facility

$120.00

Service Code	HCPCS 86880
Hospital Charge Code	8585323
Hospital Revenue Code	300
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

86880 - Cord Blood Workup

Facility

$120.00

Service Code	HCPCS 86880
Hospital Charge Code	8585323
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$60.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$66.00
Rate for Payer: Hawaii Medical Service Association ABD	$7.42
Rate for Payer: Hawaii Medical Service Association Commercial	$6.74
Rate for Payer: Hawaii Medical Service Association Medicare	$60.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.79
Rate for Payer: Hawaii Western Management Group Commercial	$5.39
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$60.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$60.00
Rate for Payer: Ohana Health Plan Medicare	$60.00
Rate for Payer: UnitedHealthcare Medicaid	$7.42
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$13.88

86890 Autol Bld Proc Stor Predep

Facility

$856.00

Service Code	HCPCS 86890
Hospital Charge Code	8258904
Hospital Revenue Code	390
Min. Negotiated Rate	$32.95
Max. Negotiated Rate	$830.32
Rate for Payer: AlohaCare Medicaid	$428.00
Rate for Payer: AlohaCare Medicare	$428.00
Rate for Payer: Cash Price	$556.40
Rate for Payer: Cash Price	$556.40
Rate for Payer: Devoted Health Medicare	$470.80
Rate for Payer: Hawaii Medical Service Association Commercial	$217.57
Rate for Payer: Hawaii Medical Service Association Medicare	$428.00
Rate for Payer: Hawaii Western Management Group Commercial	$174.06
Rate for Payer: Health Management Network Commercial	$727.60
Rate for Payer: Humana Medicare	$428.00
Rate for Payer: Kaiser Permanente Commercial	$770.40
Rate for Payer: Kaiser Permanente Medicaid	$436.56
Rate for Payer: Kaiser Permanente Medicare	$428.00
Rate for Payer: MDX Hawaii PPO	$830.32
Rate for Payer: Ohana Health Plan Medicaid	$428.00
Rate for Payer: Ohana Health Plan Medicare	$428.00
Rate for Payer: UnitedHealthcare Medicaid	$32.95
Rate for Payer: UnitedHealthcare Medicare	$428.00
Rate for Payer: University Health Alliance Commercial	$623.94

86890 Autol Bld Proc Stor Predep

Facility

$856.00

Service Code	HCPCS 86890
Hospital Charge Code	8258904
Hospital Revenue Code	390
Min. Negotiated Rate	$727.60
Max. Negotiated Rate	$830.32
Rate for Payer: Cash Price	$556.40
Rate for Payer: Health Management Network Commercial	$727.60
Rate for Payer: Kaiser Permanente Commercial	$770.40
Rate for Payer: MDX Hawaii PPO	$830.32

86901 - Cord Blood Workup

Facility

$149.00

Service Code	HCPCS 86880
Hospital Charge Code	8585322
Hospital Revenue Code	300
Min. Negotiated Rate	$5.39
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 ABD	$7.42
Rate for Payer: Hawaii Medical Service Association Commercial	$6.74
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.79
Rate for Payer: Hawaii Western Management Group Commercial	$5.39
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	$7.42
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.88

86901 - Cord Blood Workup

Facility

$149.00

Service Code	HCPCS 86880
Hospital Charge Code	8585322
Hospital Revenue Code	300
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

86905-RBC Antigens 2

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12517905
Hospital Revenue Code	302
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

86905-RBC Antigens 2

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12517905
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$9.88

86905-RBC Antigens 3

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539059
Hospital Revenue Code	302
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

86905-RBC Antigens 3

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539059
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$9.88

86905-RBC Antigens 4

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539060
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$9.88

86905-RBC Antigens 4

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539060
Hospital Revenue Code	302
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

86905-RBC Antigens 5

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539061
Hospital Revenue Code	302
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

86905-RBC Antigens 5

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539061
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$9.88

86905-RBC Antigens 6

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539062
Hospital Revenue Code	302
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

86905-RBC Antigens 6

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539062
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$9.88

86905-RBC Antigens 7

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539063
Hospital Revenue Code	302
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

86905-RBC Antigens 7

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12539063
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$9.88

86905-RBC Antigens 8

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12540275
Hospital Revenue Code	302
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

86905-RBC Antigens 8

Facility

$499.00

Service Code	HCPCS 86905
Hospital Charge Code	12540275
Hospital Revenue Code	302
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association ABD	$5.28
Rate for Payer: Hawaii Medical Service Association Commercial	$4.79
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.83
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$5.28
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$9.88

86976 PRETREAT SERUM BY DILUT SO

Facility

$244.00

Service Code	HCPCS 86976
Hospital Charge Code	9904446
Hospital Revenue Code	300
Min. Negotiated Rate	$207.40
Max. Negotiated Rate	$236.68
Rate for Payer: Cash Price	$158.60
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$219.60
Rate for Payer: MDX Hawaii PPO	$236.68

Know your out-of-pocket cost for care.

All Charges