Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

93970 Duplex scan of extremity veins; complete bilateral study

Professional

Both

$680.00

Service Code	HCPCS 93970
Hospital Charge Code	8040735
Hospital Revenue Code	975
Min. Negotiated Rate	$161.05
Max. Negotiated Rate	$578.00
Rate for Payer: AlohaCare Medicaid	$209.33
Rate for Payer: AlohaCare Medicare	$204.46
Rate for Payer: Cash Price	$442.00
Rate for Payer: Cash Price	$442.00
Rate for Payer: Devoted Health Medicare	$224.91
Rate for Payer: Hawaii Medical Service Association Medicare	$204.46
Rate for Payer: Hawaii Western Management Group Commercial	$161.05
Rate for Payer: Health Management Network Commercial	$578.00
Rate for Payer: Kaiser Permanente Commercial	$224.91
Rate for Payer: Kaiser Permanente Medicaid	$224.91
Rate for Payer: Kaiser Permanente Medicare	$224.91
Rate for Payer: Ohana Health Plan Medicaid	$209.33
Rate for Payer: Ohana Health Plan Medicare	$204.46
Rate for Payer: UnitedHealthcare Medicaid	$209.33
Rate for Payer: UnitedHealthcare Medicare	$204.46

93971 Duplex scan of extremity veins; unilateral or limited study

Professional

Both

$456.00

Service Code	HCPCS 93971
Hospital Charge Code	8040736
Hospital Revenue Code	975
Min. Negotiated Rate	$129.21
Max. Negotiated Rate	$387.60
Rate for Payer: AlohaCare Medicaid	$133.33
Rate for Payer: AlohaCare Medicare	$129.21
Rate for Payer: Cash Price	$296.40
Rate for Payer: Cash Price	$296.40
Rate for Payer: Devoted Health Medicare	$142.13
Rate for Payer: Hawaii Medical Service Association Medicare	$129.21
Rate for Payer: Hawaii Western Management Group Commercial	$130.82
Rate for Payer: Health Management Network Commercial	$387.60
Rate for Payer: Kaiser Permanente Commercial	$142.13
Rate for Payer: Kaiser Permanente Medicaid	$142.13
Rate for Payer: Kaiser Permanente Medicare	$142.13
Rate for Payer: Ohana Health Plan Medicaid	$133.33
Rate for Payer: Ohana Health Plan Medicare	$129.21
Rate for Payer: UnitedHealthcare Medicaid	$133.33
Rate for Payer: UnitedHealthcare Medicare	$129.21

93971 US Lower Ext Venous Duplex Left

Facility

$861.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	9325760
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$835.17
Rate for Payer: AlohaCare Medicaid	$430.50
Rate for Payer: AlohaCare Medicare	$430.50
Rate for Payer: Cash Price	$559.65
Rate for Payer: Cash Price	$559.65
Rate for Payer: Devoted Health Medicare	$473.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$430.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$817.95
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Humana Medicare	$430.50
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: Kaiser Permanente Medicaid	$439.11
Rate for Payer: Kaiser Permanente Medicare	$430.50
Rate for Payer: MDX Hawaii PPO	$835.17
Rate for Payer: Ohana Health Plan Medicaid	$430.50
Rate for Payer: Ohana Health Plan Medicare	$430.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$430.50
Rate for Payer: University Health Alliance Commercial	$627.58

93971 US Lower Ext Venous Duplex Left

Facility

$861.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	9325760
Hospital Revenue Code	921
Min. Negotiated Rate	$731.85
Max. Negotiated Rate	$835.17
Rate for Payer: Cash Price	$559.65
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: MDX Hawaii PPO	$835.17

93971 US Lower Ext Venous Duplex Right

Facility

$861.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	9325761
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$835.17
Rate for Payer: AlohaCare Medicaid	$430.50
Rate for Payer: AlohaCare Medicare	$430.50
Rate for Payer: Cash Price	$559.65
Rate for Payer: Cash Price	$559.65
Rate for Payer: Devoted Health Medicare	$473.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$430.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$817.95
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Humana Medicare	$430.50
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: Kaiser Permanente Medicaid	$439.11
Rate for Payer: Kaiser Permanente Medicare	$430.50
Rate for Payer: MDX Hawaii PPO	$835.17
Rate for Payer: Ohana Health Plan Medicaid	$430.50
Rate for Payer: Ohana Health Plan Medicare	$430.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$430.50
Rate for Payer: University Health Alliance Commercial	$627.58

93971 US Lower Ext Venous Duplex Right

Facility

$861.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	9325761
Hospital Revenue Code	921
Min. Negotiated Rate	$731.85
Max. Negotiated Rate	$835.17
Rate for Payer: Cash Price	$559.65
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: MDX Hawaii PPO	$835.17

93971 US Upper Ext Venous Duplex Left

Facility

$861.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	9325762
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$835.17
Rate for Payer: AlohaCare Medicaid	$430.50
Rate for Payer: AlohaCare Medicare	$430.50
Rate for Payer: Cash Price	$559.65
Rate for Payer: Cash Price	$559.65
Rate for Payer: Devoted Health Medicare	$473.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$430.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$817.95
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Humana Medicare	$430.50
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: Kaiser Permanente Medicaid	$439.11
Rate for Payer: Kaiser Permanente Medicare	$430.50
Rate for Payer: MDX Hawaii PPO	$835.17
Rate for Payer: Ohana Health Plan Medicaid	$430.50
Rate for Payer: Ohana Health Plan Medicare	$430.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$430.50
Rate for Payer: University Health Alliance Commercial	$627.58

93971 US Upper Ext Venous Duplex Left

Facility

$861.00

Service Code	HCPCS 93971 LT
Hospital Charge Code	9325762
Hospital Revenue Code	921
Min. Negotiated Rate	$731.85
Max. Negotiated Rate	$835.17
Rate for Payer: Cash Price	$559.65
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: MDX Hawaii PPO	$835.17

93971 US Upper Ext Venous Duplex Right

Facility

$861.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	9325763
Hospital Revenue Code	921
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$835.17
Rate for Payer: AlohaCare Medicaid	$430.50
Rate for Payer: AlohaCare Medicare	$430.50
Rate for Payer: Cash Price	$559.65
Rate for Payer: Cash Price	$559.65
Rate for Payer: Devoted Health Medicare	$473.55
Rate for Payer: Hawaii Medical Service Association ABD	$93.10
Rate for Payer: Hawaii Medical Service Association Medicare	$430.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$109.94
Rate for Payer: Hawaii Western Management Group Commercial	$817.95
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Humana Medicare	$430.50
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: Kaiser Permanente Medicaid	$439.11
Rate for Payer: Kaiser Permanente Medicare	$430.50
Rate for Payer: MDX Hawaii PPO	$835.17
Rate for Payer: Ohana Health Plan Medicaid	$430.50
Rate for Payer: Ohana Health Plan Medicare	$430.50
Rate for Payer: UnitedHealthcare Medicaid	$93.10
Rate for Payer: UnitedHealthcare Medicare	$430.50
Rate for Payer: University Health Alliance Commercial	$627.58

93971 US Upper Ext Venous Duplex Right

Facility

$861.00

Service Code	HCPCS 93971 RT
Hospital Charge Code	9325763
Hospital Revenue Code	921
Min. Negotiated Rate	$731.85
Max. Negotiated Rate	$835.17
Rate for Payer: Cash Price	$559.65
Rate for Payer: Health Management Network Commercial	$731.85
Rate for Payer: Kaiser Permanente Commercial	$774.90
Rate for Payer: MDX Hawaii PPO	$835.17

93975 Duplex scan of arterial inflow and venous outflow; complete study

Professional

Both

$758.00

Service Code	HCPCS 93975
Hospital Charge Code	8040737
Hospital Revenue Code	975
Min. Negotiated Rate	$264.52
Max. Negotiated Rate	$644.30
Rate for Payer: AlohaCare Medicaid	$295.00
Rate for Payer: AlohaCare Medicare	$287.11
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$315.82
Rate for Payer: Hawaii Medical Service Association Medicare	$287.11
Rate for Payer: Hawaii Western Management Group Commercial	$264.52
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$315.82
Rate for Payer: Kaiser Permanente Medicaid	$315.82
Rate for Payer: Kaiser Permanente Medicare	$315.82
Rate for Payer: Ohana Health Plan Medicaid	$295.00
Rate for Payer: Ohana Health Plan Medicare	$287.11
Rate for Payer: UnitedHealthcare Medicaid	$295.00
Rate for Payer: UnitedHealthcare Medicare	$287.11

93990 Duplex scan of hemodialysis access

Facility

$758.00

Service Code	HCPCS 93990
Hospital Charge Code	8040743
Hospital Revenue Code	921
Min. Negotiated Rate	$102.96
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$102.96
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.94
Rate for Payer: Hawaii Western Management Group Commercial	$720.10
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$102.96
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$552.51

93990 Duplex scan of hemodialysis access

Facility

$758.00

Service Code	HCPCS 93990
Hospital Charge Code	8040743
Hospital Revenue Code	921
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

94617 EXERCISE TEST FOR BRONCHOSPASM CHARGE

Facility

$679.00

Service Code	HCPCS 94617
Hospital Charge Code	8243389
Hospital Revenue Code	460
Min. Negotiated Rate	$43.09
Max. Negotiated Rate	$658.63
Rate for Payer: AlohaCare Medicaid	$339.50
Rate for Payer: AlohaCare Medicare	$339.50
Rate for Payer: Cash Price	$441.35
Rate for Payer: Cash Price	$441.35
Rate for Payer: Devoted Health Medicare	$373.45
Rate for Payer: Hawaii Medical Service Association ABD	$43.09
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$339.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.98
Rate for Payer: Hawaii Western Management Group Commercial	$645.05
Rate for Payer: Health Management Network Commercial	$577.15
Rate for Payer: Humana Medicare	$339.50
Rate for Payer: Kaiser Permanente Commercial	$611.10
Rate for Payer: Kaiser Permanente Medicaid	$346.29
Rate for Payer: Kaiser Permanente Medicare	$339.50
Rate for Payer: MDX Hawaii PPO	$658.63
Rate for Payer: Ohana Health Plan Medicaid	$339.50
Rate for Payer: Ohana Health Plan Medicare	$339.50
Rate for Payer: UnitedHealthcare Medicaid	$97.87
Rate for Payer: UnitedHealthcare Medicare	$339.50
Rate for Payer: University Health Alliance Commercial	$494.92

94617 EXERCISE TEST FOR BRONCHOSPASM CHARGE

Facility

$679.00

Service Code	HCPCS 94617
Hospital Charge Code	8243389
Hospital Revenue Code	460
Min. Negotiated Rate	$577.15
Max. Negotiated Rate	$658.63
Rate for Payer: Cash Price	$441.35
Rate for Payer: Health Management Network Commercial	$577.15
Rate for Payer: Kaiser Permanente Commercial	$611.10
Rate for Payer: MDX Hawaii PPO	$658.63

94621 PULMONARY REHAB - PERFORMANCE TEST (15 M ) CHARGE

Professional

Both

$519.00

Service Code	HCPCS 94621
Hospital Charge Code	8542829
Hospital Revenue Code	976
Min. Negotiated Rate	$130.82
Max. Negotiated Rate	$441.15
Rate for Payer: AlohaCare Medicaid	$168.27
Rate for Payer: AlohaCare Medicare	$180.37
Rate for Payer: Cash Price	$337.35
Rate for Payer: Cash Price	$337.35
Rate for Payer: Devoted Health Medicare	$198.41
Rate for Payer: Hawaii Medical Service Association Medicare	$180.37
Rate for Payer: Hawaii Western Management Group Commercial	$130.82
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Kaiser Permanente Commercial	$198.41
Rate for Payer: Kaiser Permanente Medicaid	$198.41
Rate for Payer: Kaiser Permanente Medicare	$198.41
Rate for Payer: Ohana Health Plan Medicaid	$168.27
Rate for Payer: Ohana Health Plan Medicare	$180.37
Rate for Payer: UnitedHealthcare Medicaid	$168.27
Rate for Payer: UnitedHealthcare Medicare	$180.37

94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction

Professional

Both

$63.00

Service Code	HCPCS 94640
Hospital Charge Code	8040758
Hospital Revenue Code	975
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$53.55
Rate for Payer: AlohaCare Medicaid	$8.98
Rate for Payer: AlohaCare Medicare	$9.69
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$10.66
Rate for Payer: Hawaii Medical Service Association Medicare	$9.69
Rate for Payer: Hawaii Western Management Group Commercial	$17.23
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$10.66
Rate for Payer: Kaiser Permanente Medicaid	$10.66
Rate for Payer: Kaiser Permanente Medicare	$10.66
Rate for Payer: Ohana Health Plan Medicaid	$8.98
Rate for Payer: Ohana Health Plan Medicare	$9.69
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$9.69

94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations

Professional

Both

$11.00

Service Code	HCPCS 94761
Hospital Charge Code	8040765
Hospital Revenue Code	975
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$28.79
Rate for Payer: AlohaCare Medicaid	$4.39
Rate for Payer: AlohaCare Medicare	$4.75
Rate for Payer: Cash Price	$7.15
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$5.22
Rate for Payer: Hawaii Medical Service Association Medicare	$4.75
Rate for Payer: Hawaii Western Management Group Commercial	$28.79
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$5.22
Rate for Payer: Kaiser Permanente Medicaid	$5.22
Rate for Payer: Kaiser Permanente Medicare	$5.22
Rate for Payer: Ohana Health Plan Medicaid	$4.39
Rate for Payer: Ohana Health Plan Medicare	$4.75
Rate for Payer: UnitedHealthcare Medicaid	$4.39
Rate for Payer: UnitedHealthcare Medicare	$4.75

94780 Car Seat/Bed Testing for Airway Integrity Infant - 12 MO

Professional

Both

$90.00

Service Code	HCPCS 94780
Hospital Charge Code	10314818
Hospital Revenue Code	410
Min. Negotiated Rate	$20.41
Max. Negotiated Rate	$76.50
Rate for Payer: AlohaCare Medicaid	$23.42
Rate for Payer: AlohaCare Medicare	$20.41
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Devoted Health Medicare	$22.45
Rate for Payer: Hawaii Medical Service Association ABD	$23.42
Rate for Payer: Hawaii Medical Service Association Medicare	$20.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.42
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$22.45
Rate for Payer: Kaiser Permanente Medicaid	$22.45
Rate for Payer: Kaiser Permanente Medicare	$22.45
Rate for Payer: Ohana Health Plan Medicaid	$23.42
Rate for Payer: Ohana Health Plan Medicare	$20.41
Rate for Payer: UnitedHealthcare Medicaid	$23.42
Rate for Payer: UnitedHealthcare Medicare	$20.41
Rate for Payer: University Health Alliance Commercial	$28.80

95816 EEG INCL REC AWAKE/DROWSY ProFee

Professional

Both

$939.00

Service Code	HCPCS 95816
Hospital Charge Code	8022316
Hospital Revenue Code	981
Min. Negotiated Rate	$105.68
Max. Negotiated Rate	$798.15
Rate for Payer: AlohaCare Medicaid	$445.92
Rate for Payer: AlohaCare Medicare	$463.48
Rate for Payer: Cash Price	$610.35
Rate for Payer: Cash Price	$610.35
Rate for Payer: Devoted Health Medicare	$509.83
Rate for Payer: Hawaii Medical Service Association Medicare	$463.48
Rate for Payer: Hawaii Western Management Group Commercial	$105.68
Rate for Payer: Health Management Network Commercial	$798.15
Rate for Payer: Kaiser Permanente Commercial	$509.83
Rate for Payer: Kaiser Permanente Medicaid	$509.83
Rate for Payer: Kaiser Permanente Medicare	$509.83
Rate for Payer: Ohana Health Plan Medicaid	$445.92
Rate for Payer: Ohana Health Plan Medicare	$463.48
Rate for Payer: UnitedHealthcare Medicaid	$445.92
Rate for Payer: UnitedHealthcare Medicare	$463.48

95816 Electroencephalogram (EEG); including Wake & Sleep 20 - 40 Min

Facility

$1,330.00

Service Code	HCPCS 95816
Hospital Charge Code	8040806
Hospital Revenue Code	740
Min. Negotiated Rate	$84.17
Max. Negotiated Rate	$1,290.10
Rate for Payer: AlohaCare Medicaid	$665.00
Rate for Payer: AlohaCare Medicare	$665.00
Rate for Payer: Cash Price	$864.50
Rate for Payer: Cash Price	$864.50
Rate for Payer: Devoted Health Medicare	$731.50
Rate for Payer: Hawaii Medical Service Association ABD	$84.17
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$665.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$145.63
Rate for Payer: Hawaii Western Management Group Commercial	$1,263.50
Rate for Payer: Health Management Network Commercial	$1,130.50
Rate for Payer: Humana Medicare	$665.00
Rate for Payer: Kaiser Permanente Commercial	$1,197.00
Rate for Payer: Kaiser Permanente Medicaid	$678.30
Rate for Payer: Kaiser Permanente Medicare	$665.00
Rate for Payer: MDX Hawaii PPO	$1,290.10
Rate for Payer: Ohana Health Plan Medicaid	$665.00
Rate for Payer: Ohana Health Plan Medicare	$665.00
Rate for Payer: UnitedHealthcare Medicaid	$84.17
Rate for Payer: UnitedHealthcare Medicare	$665.00
Rate for Payer: University Health Alliance Commercial	$969.44

95816 Electroencephalogram (EEG); including Wake & Sleep 20 - 40 Min

Facility

$1,330.00

Service Code	HCPCS 95816
Hospital Charge Code	8040806
Hospital Revenue Code	740
Min. Negotiated Rate	$1,130.50
Max. Negotiated Rate	$1,290.10
Rate for Payer: Cash Price	$864.50
Rate for Payer: Health Management Network Commercial	$1,130.50
Rate for Payer: Kaiser Permanente Commercial	$1,197.00
Rate for Payer: MDX Hawaii PPO	$1,290.10

96125 - Std Cognigative Performance Test

Facility

$218.00

Service Code	HCPCS 96125 GP,CQ
Hospital Charge Code	8409224
Hospital Revenue Code	440
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: MDX Hawaii PPO	$211.46

96125 - Std Cognigative Performance Test

Facility

$218.00

Service Code	HCPCS 96125 GP,CQ
Hospital Charge Code	8409224
Hospital Revenue Code	440
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$211.46
Rate for Payer: AlohaCare Medicaid	$109.00
Rate for Payer: AlohaCare Medicare	$109.00
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$119.90
Rate for Payer: Hawaii Medical Service Association Medicare	$109.00
Rate for Payer: Hawaii Western Management Group Commercial	$207.10
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Humana Medicare	$109.00
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: Kaiser Permanente Medicare	$109.00
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: Ohana Health Plan Medicaid	$109.00
Rate for Payer: Ohana Health Plan Medicare	$109.00
Rate for Payer: UnitedHealthcare Medicaid	$41.65
Rate for Payer: UnitedHealthcare Medicare	$109.00
Rate for Payer: University Health Alliance Commercial	$158.90

96360-59 IV Hydration Initial Addl Site w/ Modification

Facility

$664.00

Service Code	HCPCS 96360 59
Hospital Charge Code	8079986
Hospital Revenue Code	450
Min. Negotiated Rate	$564.40
Max. Negotiated Rate	$644.08
Rate for Payer: Cash Price	$431.60
Rate for Payer: Health Management Network Commercial	$564.40
Rate for Payer: Kaiser Permanente Commercial	$597.60
Rate for Payer: MDX Hawaii PPO	$644.08

Know your out-of-pocket cost for care.

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