Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

96375-IV Push Each Additional New Drug

Facility

$325.00

Service Code	HCPCS 96375
Hospital Charge Code	8079983
Hospital Revenue Code	450
Min. Negotiated Rate	$276.25
Max. Negotiated Rate	$315.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Kaiser Permanente Commercial	$292.50
Rate for Payer: MDX Hawaii PPO	$315.25

96376- ED IV Injection, add same drug

Facility

$257.00

Service Code	HCPCS 96376
Hospital Charge Code	1928307
Hospital Revenue Code	450
Min. Negotiated Rate	$128.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$187.33

96376- ED IV Injection, add same drug

Facility

$257.00

Service Code	HCPCS 96376
Hospital Charge Code	1928307
Hospital Revenue Code	450
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

96376 IV Push Addl Same Drug > 30Min Charge

Facility

$257.00

Service Code	HCPCS 96376
Hospital Charge Code	8220034
Hospital Revenue Code	940
Min. Negotiated Rate	$128.50
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$187.33

96376 IV Push Addl Same Drug > 30Min Charge

Facility

$257.00

Service Code	HCPCS 96376
Hospital Charge Code	8220034
Hospital Revenue Code	940
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

96376-IV Push Addl Same Drug Greater Than 30 mins

Facility

$257.00

Service Code	HCPCS 96376
Hospital Charge Code	8079985
Hospital Revenue Code	450
Min. Negotiated Rate	$128.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$128.50
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Devoted Health Medicare	$141.35
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$128.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$128.50
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$128.50
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$128.50
Rate for Payer: Ohana Health Plan Medicare	$128.50
Rate for Payer: UnitedHealthcare Medicare	$128.50
Rate for Payer: University Health Alliance Commercial	$187.33

96376-IV Push Addl Same Drug Greater Than 30 mins

Facility

$257.00

Service Code	HCPCS 96376
Hospital Charge Code	8079985
Hospital Revenue Code	450
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

96379 Unlisted IV Inj or Inf Charge

Facility

$260.00

Service Code	HCPCS 96379
Hospital Charge Code	8220037
Hospital Revenue Code	940
Min. Negotiated Rate	$34.61
Max. Negotiated Rate	$252.20
Rate for Payer: AlohaCare Medicaid	$130.00
Rate for Payer: AlohaCare Medicare	$130.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Devoted Health Medicare	$143.00
Rate for Payer: Hawaii Medical Service Association Commercial	$59.80
Rate for Payer: Hawaii Medical Service Association Medicare	$130.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Humana Medicare	$130.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: Kaiser Permanente Medicare	$130.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: Ohana Health Plan Medicaid	$130.00
Rate for Payer: Ohana Health Plan Medicare	$130.00
Rate for Payer: UnitedHealthcare Medicaid	$34.61
Rate for Payer: UnitedHealthcare Medicare	$130.00
Rate for Payer: University Health Alliance Commercial	$189.51

96379 Unlisted IV Inj or Inf Charge

Facility

$260.00

Service Code	HCPCS 96379
Hospital Charge Code	8220037
Hospital Revenue Code	940
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$169.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$234.00
Rate for Payer: MDX Hawaii PPO	$252.20

96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc

Facility

$147.00

Service Code	HCPCS 96380
Hospital Charge Code	12351125
Hospital Revenue Code	771
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc

Facility

$147.00

Service Code	HCPCS 96380
Hospital Charge Code	12351125
Hospital Revenue Code	771
Min. Negotiated Rate	$14.77
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$14.77
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$107.15

96380 Adminstration of Beyfortus w/counseling

Facility

$147.00

Service Code	HCPCS 96380
Hospital Charge Code	12114523
Hospital Revenue Code	771
Min. Negotiated Rate	$14.77
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Western Management Group Commercial	$139.65
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$14.77
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$107.15

96380 Adminstration of Beyfortus w/counseling

Facility

$147.00

Service Code	HCPCS 96380
Hospital Charge Code	12114523
Hospital Revenue Code	771
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

96380 VFC Adminstration of Beyfortus w/counseling

Facility

$28.00

Service Code	HCPCS 96380
Hospital Charge Code	12124363
Hospital Revenue Code	771
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$27.16
Rate for Payer: Cash Price	$18.20
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: MDX Hawaii PPO	$27.16

96380 VFC Adminstration of Beyfortus w/counseling

Facility

$28.00

Service Code	HCPCS 96380
Hospital Charge Code	12124363
Hospital Revenue Code	771
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$27.16
Rate for Payer: AlohaCare Medicaid	$14.00
Rate for Payer: AlohaCare Medicare	$14.00
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cash Price	$18.20
Rate for Payer: Devoted Health Medicare	$15.40
Rate for Payer: Hawaii Medical Service Association Medicare	$14.00
Rate for Payer: Hawaii Western Management Group Commercial	$26.60
Rate for Payer: Health Management Network Commercial	$23.80
Rate for Payer: Humana Medicare	$14.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$14.28
Rate for Payer: Kaiser Permanente Medicare	$14.00
Rate for Payer: MDX Hawaii PPO	$27.16
Rate for Payer: Ohana Health Plan Medicaid	$14.00
Rate for Payer: Ohana Health Plan Medicare	$14.00
Rate for Payer: UnitedHealthcare Medicaid	$14.77
Rate for Payer: UnitedHealthcare Medicare	$14.00
Rate for Payer: University Health Alliance Commercial	$20.41

96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc

Facility

$120.00

Service Code	HCPCS 96381
Hospital Charge Code	12351126
Hospital Revenue Code	771
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

96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramusc

Facility

$120.00

Service Code	HCPCS 96381
Hospital Charge Code	12351126
Hospital Revenue Code	771
Min. Negotiated Rate	$12.92
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 Medicare	$60.00
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
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	$12.92
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$87.47

96521 REFILL MAINT PORTABLE PUMP CHARGE

Facility

$864.00

Service Code	HCPCS 96521
Hospital Charge Code	8221510
Hospital Revenue Code	761
Min. Negotiated Rate	$101.13
Max. Negotiated Rate	$838.08
Rate for Payer: AlohaCare Medicaid	$432.00
Rate for Payer: AlohaCare Medicare	$432.00
Rate for Payer: Cash Price	$561.60
Rate for Payer: Cash Price	$561.60
Rate for Payer: Devoted Health Medicare	$475.20
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$432.00
Rate for Payer: Hawaii Western Management Group Commercial	$820.80
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Humana Medicare	$432.00
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: Kaiser Permanente Medicaid	$440.64
Rate for Payer: Kaiser Permanente Medicare	$432.00
Rate for Payer: MDX Hawaii PPO	$838.08
Rate for Payer: Ohana Health Plan Medicaid	$432.00
Rate for Payer: Ohana Health Plan Medicare	$432.00
Rate for Payer: UnitedHealthcare Medicaid	$101.13
Rate for Payer: UnitedHealthcare Medicare	$432.00
Rate for Payer: University Health Alliance Commercial	$629.77

96521 REFILL MAINT PORTABLE PUMP CHARGE

Facility

$864.00

Service Code	HCPCS 96521
Hospital Charge Code	8221510
Hospital Revenue Code	761
Min. Negotiated Rate	$734.40
Max. Negotiated Rate	$838.08
Rate for Payer: Cash Price	$561.60
Rate for Payer: Health Management Network Commercial	$734.40
Rate for Payer: Kaiser Permanente Commercial	$777.60
Rate for Payer: MDX Hawaii PPO	$838.08

96523 Irrig Drug Delivery Device Charges

Facility

$160.00

Service Code	HCPCS 96523
Hospital Charge Code	8221505
Hospital Revenue Code	761
Min. Negotiated Rate	$20.64
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association Commercial	$75.34
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicaid	$20.64
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$116.62

96523 Irrig Drug Delivery Device Charges

Facility

$160.00

Service Code	HCPCS 96523
Hospital Charge Code	8221505
Hospital Revenue Code	761
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

96900 Actinotherapy (ultraviolet light)

Facility

$139.00

Service Code	HCPCS 96900
Hospital Charge Code	8040863
Hospital Revenue Code	940
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association Commercial	$47.70
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Western Management Group Commercial	$132.05
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$13.29
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$101.32

96900 Actinotherapy (ultraviolet light)

Professional

Both

$52.00

Service Code	HCPCS 96900
Hospital Charge Code	8040863
Hospital Revenue Code	960
Min. Negotiated Rate	$12.76
Max. Negotiated Rate	$44.20
Rate for Payer: AlohaCare Medicaid	$28.49
Rate for Payer: AlohaCare Medicare	$26.78
Rate for Payer: Cash Price	$33.80
Rate for Payer: Cash Price	$33.80
Rate for Payer: Devoted Health Medicare	$29.46
Rate for Payer: Hawaii Medical Service Association Medicare	$26.78
Rate for Payer: Hawaii Western Management Group Commercial	$12.76
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Kaiser Permanente Commercial	$29.46
Rate for Payer: Kaiser Permanente Medicaid	$29.46
Rate for Payer: Kaiser Permanente Medicare	$29.46
Rate for Payer: Ohana Health Plan Medicaid	$28.49
Rate for Payer: Ohana Health Plan Medicare	$26.78
Rate for Payer: UnitedHealthcare Medicaid	$28.49
Rate for Payer: UnitedHealthcare Medicare	$26.78

96900 Actinotherapy (ultraviolet light)

Facility

$139.00

Service Code	HCPCS 96900
Hospital Charge Code	8040863
Hospital Revenue Code	940
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

97012 Traction Mechanical

Facility

$127.00

Service Code	HCPCS 97012 GP,CQ
Hospital Charge Code	8222667
Hospital Revenue Code	430
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

Know your out-of-pocket cost for care.

All Charges