Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

90480 COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	11638728
Hospital Revenue Code	771
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$55.25
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$82.45

90480 COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	11638728
Hospital Revenue Code	771
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$82.45
Rate for Payer: AlohaCare Medicaid	$42.50
Rate for Payer: AlohaCare Medicare	$42.50
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$46.75
Rate for Payer: Hawaii Medical Service Association ABD	$47.20
Rate for Payer: Hawaii Medical Service Association Commercial	$51.90
Rate for Payer: Hawaii Medical Service Association Medicare	$42.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.20
Rate for Payer: Hawaii Western Management Group Commercial	$80.75
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Humana Medicare	$42.50
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: Kaiser Permanente Medicare	$42.50
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: Ohana Health Plan Medicaid	$42.50
Rate for Payer: Ohana Health Plan Medicare	$42.50
Rate for Payer: UnitedHealthcare Medicaid	$31.14
Rate for Payer: UnitedHealthcare Medicare	$42.50
Rate for Payer: University Health Alliance Commercial	$61.96

90480-COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	12108792
Hospital Revenue Code	771
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$82.45
Rate for Payer: AlohaCare Medicaid	$42.50
Rate for Payer: AlohaCare Medicare	$42.50
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$46.75
Rate for Payer: Hawaii Medical Service Association ABD	$47.20
Rate for Payer: Hawaii Medical Service Association Commercial	$51.90
Rate for Payer: Hawaii Medical Service Association Medicare	$42.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.20
Rate for Payer: Hawaii Western Management Group Commercial	$80.75
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Humana Medicare	$42.50
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: Kaiser Permanente Medicare	$42.50
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: Ohana Health Plan Medicaid	$42.50
Rate for Payer: Ohana Health Plan Medicare	$42.50
Rate for Payer: UnitedHealthcare Medicaid	$31.14
Rate for Payer: UnitedHealthcare Medicare	$42.50
Rate for Payer: University Health Alliance Commercial	$61.96

90480-COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	12108792
Hospital Revenue Code	771
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$55.25
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$82.45

90653 High dose influenza virus vaccine (2025-2026 Fluad 0.5mL, 65 yrs & older)

Facility

$104.00

Service Code	HCPCS 90653
Hospital Charge Code	13245282
Hospital Revenue Code	771
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

90653 High dose influenza virus vaccine (2025-2026 Fluad 0.5mL, 65 yrs & older)

Facility

$104.00

Service Code	HCPCS 90653
Hospital Charge Code	13245282
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association ABD	$83.49
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$83.49
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$75.81

90653 Influenza vaccine, inactivated (Fluad) High Dose for intramuscular use

Facility

$0.01

Service Code	HCPCS 90653
Hospital Charge Code	12273679
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01

90653 Influenza vaccine, inactivated (Fluad) High Dose for intramuscular use

Facility

$0.01

Service Code	HCPCS 90653
Hospital Charge Code	12273679
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$83.49
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$83.49
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$83.49
Rate for Payer: Hawaii Western Management Group Commercial	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: Kaiser Permanente Medicaid	$0.01
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.01

90661 Flucelvax Trivalent PFS - 0.5ml IM once [<65, egg free, PFS are preservative free]

Facility

$0.01

Service Code	HCPCS 90661
Hospital Charge Code	8581243
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01

90661 Flucelvax Trivalent PFS - 0.5ml IM once [<65, egg free, PFS are preservative free]

Facility

$0.01

Service Code	HCPCS 90661
Hospital Charge Code	8581243
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.85
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$36.85
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.85
Rate for Payer: Hawaii Western Management Group Commercial	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: Kaiser Permanente Medicaid	$0.01
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.01

90671 Pneumococcal 15-valent conjugate vaccine

Facility

$408.00

Service Code	HCPCS 90671
Hospital Charge Code	10300703
Hospital Revenue Code	771
Min. Negotiated Rate	$195.86
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$204.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$224.40
Rate for Payer: Hawaii Medical Service Association ABD	$253.56
Rate for Payer: Hawaii Medical Service Association Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$253.56
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$204.00
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$204.00
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$204.00
Rate for Payer: Ohana Health Plan Medicare	$204.00
Rate for Payer: UnitedHealthcare Medicaid	$195.86
Rate for Payer: UnitedHealthcare Medicare	$204.00
Rate for Payer: University Health Alliance Commercial	$297.39

90671 Pneumococcal 15-valent conjugate vaccine

Facility

$408.00

Service Code	HCPCS 90671
Hospital Charge Code	10300703
Hospital Revenue Code	771
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

90673 FluBlok

Facility

$104.00

Service Code	HCPCS 90673
Hospital Charge Code	12411340
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association ABD	$83.49
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$83.49
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$75.81

90673 FluBlok

Facility

$104.00

Service Code	HCPCS 90673
Hospital Charge Code	12411340
Hospital Revenue Code	771
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

90674 FLUCELVAX QUADRIVALENT(PREFILLED SYRINGE)

Facility

$128.00

Service Code	HCPCS 90674
Hospital Charge Code	8750329
Hospital Revenue Code	636
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: MDX Hawaii PPO	$124.16

90674 FLUCELVAX QUADRIVALENT(PREFILLED SYRINGE)

Facility

$128.00

Service Code	HCPCS 90674
Hospital Charge Code	8750329
Hospital Revenue Code	636
Min. Negotiated Rate	$34.17
Max. Negotiated Rate	$124.16
Rate for Payer: AlohaCare Medicaid	$64.00
Rate for Payer: AlohaCare Medicare	$64.00
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$70.40
Rate for Payer: Hawaii Medical Service Association ABD	$34.17
Rate for Payer: Hawaii Medical Service Association Medicare	$64.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.17
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Humana Medicare	$64.00
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: Kaiser Permanente Medicare	$64.00
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: Ohana Health Plan Medicaid	$64.00
Rate for Payer: Ohana Health Plan Medicare	$64.00
Rate for Payer: UnitedHealthcare Medicaid	$76.80
Rate for Payer: UnitedHealthcare Medicare	$64.00
Rate for Payer: University Health Alliance Commercial	$93.30

90677-Pneumococcal 20-Valent (Prevnar 20)

Facility

$476.00

Service Code	HCPCS 90677
Hospital Charge Code	12124742
Hospital Revenue Code	636
Min. Negotiated Rate	$404.60
Max. Negotiated Rate	$461.72
Rate for Payer: Cash Price	$309.40
Rate for Payer: Health Management Network Commercial	$404.60
Rate for Payer: Kaiser Permanente Commercial	$428.40
Rate for Payer: MDX Hawaii PPO	$461.72

90677-Pneumococcal 20-Valent (Prevnar 20)

Facility

$476.00

Service Code	HCPCS 90677
Hospital Charge Code	12124742
Hospital Revenue Code	636
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$461.72
Rate for Payer: Cash Price	$309.40
Rate for Payer: AlohaCare Medicaid	$238.00
Rate for Payer: AlohaCare Medicare	$238.00
Rate for Payer: Cash Price	$309.40
Rate for Payer: Devoted Health Medicare	$261.80
Rate for Payer: Hawaii Medical Service Association ABD	$298.04
Rate for Payer: Hawaii Medical Service Association Medicare	$238.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$298.04
Rate for Payer: Hawaii Western Management Group Commercial	$452.20
Rate for Payer: Health Management Network Commercial	$404.60
Rate for Payer: Humana Medicare	$238.00
Rate for Payer: Kaiser Permanente Commercial	$428.40
Rate for Payer: Kaiser Permanente Medicaid	$242.76
Rate for Payer: Kaiser Permanente Medicare	$238.00
Rate for Payer: MDX Hawaii PPO	$461.72
Rate for Payer: Ohana Health Plan Medicaid	$238.00
Rate for Payer: Ohana Health Plan Medicare	$238.00
Rate for Payer: UnitedHealthcare Medicaid	$285.60
Rate for Payer: UnitedHealthcare Medicare	$238.00
Rate for Payer: University Health Alliance Commercial	$346.96

90679 Abrysvo Adult RSV Vaccine

Facility

$390.00

Hospital Charge Code	11263089
Hospital Revenue Code	636
Min. Negotiated Rate	$195.00
Max. Negotiated Rate	$378.30
Rate for Payer: AlohaCare Medicaid	$195.00
Rate for Payer: AlohaCare Medicare	$195.00
Rate for Payer: Cash Price	$253.50
Rate for Payer: Devoted Health Medicare	$214.50
Rate for Payer: Hawaii Medical Service Association Medicare	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$370.50
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Humana Medicare	$195.00
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: Kaiser Permanente Medicaid	$198.90
Rate for Payer: Kaiser Permanente Medicare	$195.00
Rate for Payer: MDX Hawaii PPO	$378.30
Rate for Payer: Ohana Health Plan Medicaid	$195.00
Rate for Payer: Ohana Health Plan Medicare	$195.00
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: UnitedHealthcare Medicare	$195.00
Rate for Payer: University Health Alliance Commercial	$284.27

90679 Abrysvo Adult RSV Vaccine

Facility

$390.00

Hospital Charge Code	11263089
Hospital Revenue Code	636
Min. Negotiated Rate	$331.50
Max. Negotiated Rate	$378.30
Rate for Payer: Cash Price	$253.50
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: MDX Hawaii PPO	$378.30

91322 SARSCOV2 SPIKEVAX 2023-2024 formula 12+yrs

Facility

$486.00

Service Code	HCPCS 91322
Hospital Charge Code	11495746
Hospital Revenue Code	771
Min. Negotiated Rate	$413.10
Max. Negotiated Rate	$471.42
Rate for Payer: Cash Price	$315.90
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Kaiser Permanente Commercial	$437.40
Rate for Payer: MDX Hawaii PPO	$471.42

91322 SARSCOV2 SPIKEVAX 2023-2024 formula 12+yrs

Facility

$486.00

Service Code	HCPCS 91322
Hospital Charge Code	11495746
Hospital Revenue Code	771
Min. Negotiated Rate	$121.24
Max. Negotiated Rate	$471.42
Rate for Payer: AlohaCare Medicaid	$243.00
Rate for Payer: AlohaCare Medicare	$243.00
Rate for Payer: Cash Price	$315.90
Rate for Payer: Cash Price	$315.90
Rate for Payer: Devoted Health Medicare	$267.30
Rate for Payer: Hawaii Medical Service Association ABD	$153.14
Rate for Payer: Hawaii Medical Service Association Medicare	$243.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$153.14
Rate for Payer: Hawaii Western Management Group Commercial	$461.70
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Humana Medicare	$243.00
Rate for Payer: Kaiser Permanente Commercial	$437.40
Rate for Payer: Kaiser Permanente Medicaid	$247.86
Rate for Payer: Kaiser Permanente Medicare	$243.00
Rate for Payer: MDX Hawaii PPO	$471.42
Rate for Payer: Ohana Health Plan Medicaid	$243.00
Rate for Payer: Ohana Health Plan Medicare	$243.00
Rate for Payer: UnitedHealthcare Medicaid	$121.24
Rate for Payer: UnitedHealthcare Medicare	$243.00
Rate for Payer: University Health Alliance Commercial	$354.25

92508 - Speech Therapy Group Charge

Facility

$177.00

Service Code	HCPCS 92508 GP,CQ
Hospital Charge Code	8409547
Hospital Revenue Code	440
Min. Negotiated Rate	$11.15
Max. Negotiated Rate	$171.69
Rate for Payer: AlohaCare Medicaid	$88.50
Rate for Payer: AlohaCare Medicare	$88.50
Rate for Payer: Cash Price	$115.05
Rate for Payer: Cash Price	$115.05
Rate for Payer: Devoted Health Medicare	$97.35
Rate for Payer: Hawaii Medical Service Association Medicare	$88.50
Rate for Payer: Hawaii Western Management Group Commercial	$168.15
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Humana Medicare	$88.50
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: Kaiser Permanente Medicaid	$90.27
Rate for Payer: Kaiser Permanente Medicare	$88.50
Rate for Payer: MDX Hawaii PPO	$171.69
Rate for Payer: Ohana Health Plan Medicaid	$88.50
Rate for Payer: Ohana Health Plan Medicare	$88.50
Rate for Payer: UnitedHealthcare Medicaid	$11.15
Rate for Payer: UnitedHealthcare Medicare	$88.50
Rate for Payer: University Health Alliance Commercial	$129.02

92508 - Speech Therapy Group Charge

Facility

$177.00

Service Code	HCPCS 92508 GP,CQ
Hospital Charge Code	8409547
Hospital Revenue Code	440
Min. Negotiated Rate	$150.45
Max. Negotiated Rate	$171.69
Rate for Payer: Cash Price	$115.05
Rate for Payer: Health Management Network Commercial	$150.45
Rate for Payer: Kaiser Permanente Commercial	$159.30
Rate for Payer: MDX Hawaii PPO	$171.69

92511 Nasopharyngoscopy with endoscope

Facility

$1,093.00

Service Code	HCPCS 92511
Hospital Charge Code	11043542
Hospital Revenue Code	450
Min. Negotiated Rate	$929.05
Max. Negotiated Rate	$1,060.21
Rate for Payer: Cash Price	$710.45
Rate for Payer: Health Management Network Commercial	$929.05
Rate for Payer: Kaiser Permanente Commercial	$983.70
Rate for Payer: MDX Hawaii PPO	$1,060.21

Know your out-of-pocket cost for care.

All Charges