Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

99157 CONS SEDATE EA ADD 15MIN DIFF PROVI ProFee

Professional

Both

$93.00

Service Code	HCPCS 99157
Hospital Charge Code	8022401
Hospital Revenue Code	963
Min. Negotiated Rate	$53.19
Max. Negotiated Rate	$79.05
Rate for Payer: AlohaCare Medicaid	$58.96
Rate for Payer: AlohaCare Medicare	$53.19
Rate for Payer: Cash Price	$60.45
Rate for Payer: Cash Price	$60.45
Rate for Payer: Devoted Health Medicare	$58.51
Rate for Payer: Hawaii Medical Service Association Medicare	$53.19
Rate for Payer: Hawaii Western Management Group Commercial	$58.56
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$58.51
Rate for Payer: Kaiser Permanente Medicaid	$58.51
Rate for Payer: Kaiser Permanente Medicare	$58.51
Rate for Payer: Ohana Health Plan Medicaid	$58.96
Rate for Payer: Ohana Health Plan Medicare	$53.19
Rate for Payer: UnitedHealthcare Medicaid	$58.96
Rate for Payer: UnitedHealthcare Medicare	$53.19

99157-Different MD Each Addl 15 mins

Facility

$70.00

Service Code	HCPCS 99157
Hospital Charge Code	8080169
Hospital Revenue Code	370
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: MDX Hawaii PPO	$67.90

99157-Different MD Each Addl 15 mins

Facility

$70.00

Service Code	HCPCS 99157
Hospital Charge Code	8080169
Hospital Revenue Code	370
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$67.90
Rate for Payer: AlohaCare Medicaid	$35.00
Rate for Payer: AlohaCare Medicare	$35.00
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Devoted Health Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Medicare	$35.00
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Humana Medicare	$35.00
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: Kaiser Permanente Medicare	$35.00
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: Ohana Health Plan Medicaid	$35.00
Rate for Payer: Ohana Health Plan Medicare	$35.00
Rate for Payer: UnitedHealthcare Medicaid	$58.96
Rate for Payer: UnitedHealthcare Medicare	$35.00
Rate for Payer: University Health Alliance Commercial	$51.02

99195 Phlebotomy, therapeutic

Professional

Both

$275.00

Service Code	HCPCS 99195
Hospital Charge Code	8040930
Hospital Revenue Code	975
Min. Negotiated Rate	$18.61
Max. Negotiated Rate	$233.75
Rate for Payer: AlohaCare Medicaid	$108.60
Rate for Payer: AlohaCare Medicare	$110.72
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Devoted Health Medicare	$121.79
Rate for Payer: Hawaii Medical Service Association Medicare	$110.72
Rate for Payer: Hawaii Western Management Group Commercial	$18.61
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$121.79
Rate for Payer: Kaiser Permanente Medicaid	$121.79
Rate for Payer: Kaiser Permanente Medicare	$121.79
Rate for Payer: Ohana Health Plan Medicaid	$108.60
Rate for Payer: Ohana Health Plan Medicare	$110.72
Rate for Payer: UnitedHealthcare Medicaid	$108.60
Rate for Payer: UnitedHealthcare Medicare	$110.72

99195††PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE

Facility

$550.00

Service Code	HCPCS 99195
Hospital Charge Code	8258871
Hospital Revenue Code	940
Min. Negotiated Rate	$467.50
Max. Negotiated Rate	$533.50
Rate for Payer: Cash Price	$357.50
Rate for Payer: Health Management Network Commercial	$467.50
Rate for Payer: Kaiser Permanente Commercial	$495.00
Rate for Payer: MDX Hawaii PPO	$533.50

99195††PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE

Facility

$550.00

Service Code	HCPCS 99195
Hospital Charge Code	8258871
Hospital Revenue Code	940
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$533.50
Rate for Payer: AlohaCare Medicaid	$275.00
Rate for Payer: AlohaCare Medicare	$275.00
Rate for Payer: Cash Price	$357.50
Rate for Payer: Cash Price	$357.50
Rate for Payer: Devoted Health Medicare	$302.50
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$275.00
Rate for Payer: Hawaii Western Management Group Commercial	$522.50
Rate for Payer: Health Management Network Commercial	$467.50
Rate for Payer: Humana Medicare	$275.00
Rate for Payer: Kaiser Permanente Commercial	$495.00
Rate for Payer: Kaiser Permanente Medicaid	$280.50
Rate for Payer: Kaiser Permanente Medicare	$275.00
Rate for Payer: MDX Hawaii PPO	$533.50
Rate for Payer: Ohana Health Plan Medicaid	$275.00
Rate for Payer: Ohana Health Plan Medicare	$275.00
Rate for Payer: UnitedHealthcare Medicaid	$14.85
Rate for Payer: UnitedHealthcare Medicare	$275.00
Rate for Payer: University Health Alliance Commercial	$400.89

99203 Office/Outpatient Visit - New Patient, Level 3 (30-44 min)

Professional

Both

$117.00

Service Code	HCPCS 99203
Hospital Charge Code	8041014
Hospital Revenue Code	981
Min. Negotiated Rate	$70.97
Max. Negotiated Rate	$99.45
Rate for Payer: AlohaCare Medicaid	$82.26
Rate for Payer: AlohaCare Medicare	$70.97
Rate for Payer: Cash Price	$76.05
Rate for Payer: Cash Price	$76.05
Rate for Payer: Devoted Health Medicare	$78.07
Rate for Payer: Hawaii Medical Service Association ABD	$82.26
Rate for Payer: Hawaii Medical Service Association Medicare	$70.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.26
Rate for Payer: Hawaii Western Management Group Commercial	$77.24
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Kaiser Permanente Commercial	$78.07
Rate for Payer: Kaiser Permanente Medicaid	$78.07
Rate for Payer: Kaiser Permanente Medicare	$78.07
Rate for Payer: Ohana Health Plan Medicaid	$82.26
Rate for Payer: Ohana Health Plan Medicare	$70.97
Rate for Payer: UnitedHealthcare Medicaid	$82.26
Rate for Payer: UnitedHealthcare Medicare	$70.97

99211 Nurse Office/Outpatient Visit - Established Patient, Level 1

Professional

Both

$85.00

Service Code	HCPCS 99211
Hospital Charge Code	8041017
Hospital Revenue Code	982
Min. Negotiated Rate	$7.72
Max. Negotiated Rate	$72.25
Rate for Payer: AlohaCare Medicaid	$8.86
Rate for Payer: AlohaCare Medicare	$7.72
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$8.49
Rate for Payer: Hawaii Medical Service Association ABD	$8.86
Rate for Payer: Hawaii Medical Service Association Medicare	$7.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.86
Rate for Payer: Hawaii Western Management Group Commercial	$17.23
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$8.49
Rate for Payer: Kaiser Permanente Medicaid	$8.49
Rate for Payer: Kaiser Permanente Medicare	$8.49
Rate for Payer: Ohana Health Plan Medicaid	$8.86
Rate for Payer: Ohana Health Plan Medicare	$7.72
Rate for Payer: UnitedHealthcare Medicaid	$8.86
Rate for Payer: UnitedHealthcare Medicare	$7.72

99212 Office/Outpatient Visit - Established Patient, Level 2

Professional

Both

$74.00

Service Code	HCPCS 99212
Hospital Charge Code	8041018
Hospital Revenue Code	982
Min. Negotiated Rate	$29.59
Max. Negotiated Rate	$62.90
Rate for Payer: AlohaCare Medicaid	$35.51
Rate for Payer: AlohaCare Medicare	$31.00
Rate for Payer: Cash Price	$48.10
Rate for Payer: Cash Price	$48.10
Rate for Payer: Devoted Health Medicare	$34.10
Rate for Payer: Hawaii Medical Service Association ABD	$35.51
Rate for Payer: Hawaii Medical Service Association Medicare	$31.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$35.51
Rate for Payer: Hawaii Western Management Group Commercial	$29.59
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$34.10
Rate for Payer: Kaiser Permanente Medicaid	$34.10
Rate for Payer: Kaiser Permanente Medicare	$34.10
Rate for Payer: Ohana Health Plan Medicaid	$35.51
Rate for Payer: Ohana Health Plan Medicare	$31.00
Rate for Payer: UnitedHealthcare Medicaid	$35.51
Rate for Payer: UnitedHealthcare Medicare	$31.00

99215 Office/Outpatient Visit - Established Patient, Level 5 (40-54 min).

Professional

Both

$565.00

Service Code	HCPCS 99215
Hospital Charge Code	8041021
Hospital Revenue Code	975
Min. Negotiated Rate	$83.80
Max. Negotiated Rate	$480.25
Rate for Payer: AlohaCare Medicaid	$145.89
Rate for Payer: AlohaCare Medicare	$126.07
Rate for Payer: Cash Price	$367.25
Rate for Payer: Cash Price	$367.25
Rate for Payer: Devoted Health Medicare	$138.68
Rate for Payer: Hawaii Medical Service Association ABD	$145.89
Rate for Payer: Hawaii Medical Service Association Medicare	$126.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$145.89
Rate for Payer: Hawaii Western Management Group Commercial	$83.80
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Kaiser Permanente Commercial	$138.68
Rate for Payer: Kaiser Permanente Medicaid	$138.68
Rate for Payer: Kaiser Permanente Medicare	$138.68
Rate for Payer: Ohana Health Plan Medicaid	$145.89
Rate for Payer: Ohana Health Plan Medicare	$126.07
Rate for Payer: UnitedHealthcare Medicaid	$145.89
Rate for Payer: UnitedHealthcare Medicare	$126.07

99217 Observation Discharge Day Management

Professional

Both

$256.00

Service Code	HCPCS 99217
Hospital Charge Code	8041022
Hospital Revenue Code	975
Min. Negotiated Rate	$65.40
Max. Negotiated Rate	$217.60
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Hawaii Western Management Group Commercial	$65.40
Rate for Payer: Health Management Network Commercial	$217.60

99218 Initial Observation Visit, Low

Professional

Both

$233.00

Service Code	HCPCS 99218
Hospital Charge Code	8041023
Hospital Revenue Code	975
Min. Negotiated Rate	$72.12
Max. Negotiated Rate	$198.05
Rate for Payer: Cash Price	$151.45
Rate for Payer: Cash Price	$151.45
Rate for Payer: Hawaii Western Management Group Commercial	$72.12
Rate for Payer: Health Management Network Commercial	$198.05

99219 Initial Observation Visit, Moderate

Professional

Both

$389.00

Hospital Charge Code	8041024
Hospital Revenue Code	982
Min. Negotiated Rate	$330.65
Max. Negotiated Rate	$330.65
Rate for Payer: Cash Price	$252.85
Rate for Payer: Health Management Network Commercial	$330.65

99220 Initial Observation Visit, High

Professional

Both

$545.00

Hospital Charge Code	8041025
Hospital Revenue Code	975
Min. Negotiated Rate	$463.25
Max. Negotiated Rate	$463.25
Rate for Payer: Cash Price	$354.25
Rate for Payer: Health Management Network Commercial	$463.25

99221 Initial Hospital Care, Level 1

Professional

Both

$296.00

Service Code	HCPCS 99221
Hospital Charge Code	8041026
Hospital Revenue Code	975
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$251.60
Rate for Payer: AlohaCare Medicaid	$82.48
Rate for Payer: AlohaCare Medicare	$73.69
Rate for Payer: Cash Price	$192.40
Rate for Payer: Cash Price	$192.40
Rate for Payer: Devoted Health Medicare	$81.06
Rate for Payer: Hawaii Medical Service Association Medicare	$73.69
Rate for Payer: Hawaii Western Management Group Commercial	$68.50
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Kaiser Permanente Commercial	$81.06
Rate for Payer: Kaiser Permanente Medicaid	$81.06
Rate for Payer: Kaiser Permanente Medicare	$81.06
Rate for Payer: Ohana Health Plan Medicaid	$82.48
Rate for Payer: Ohana Health Plan Medicare	$73.69
Rate for Payer: UnitedHealthcare Medicaid	$82.48
Rate for Payer: UnitedHealthcare Medicare	$73.69

99222 Initial Hospital Care, Level 2

Professional

Both

$449.00

Service Code	HCPCS 99222
Hospital Charge Code	8041027
Hospital Revenue Code	975
Min. Negotiated Rate	$113.39
Max. Negotiated Rate	$381.65
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$116.73
Rate for Payer: Cash Price	$291.85
Rate for Payer: Cash Price	$291.85
Rate for Payer: Devoted Health Medicare	$128.40
Rate for Payer: Hawaii Medical Service Association Medicare	$116.73
Rate for Payer: Hawaii Western Management Group Commercial	$113.39
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Kaiser Permanente Commercial	$128.40
Rate for Payer: Kaiser Permanente Medicaid	$128.40
Rate for Payer: Kaiser Permanente Medicare	$128.40
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$116.73
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: UnitedHealthcare Medicare	$116.73

99223 Initial Hospital Care, Level 3

Professional

Both

$576.00

Service Code	HCPCS 99223
Hospital Charge Code	8041028
Hospital Revenue Code	975
Min. Negotiated Rate	$149.55
Max. Negotiated Rate	$489.60
Rate for Payer: AlohaCare Medicaid	$174.14
Rate for Payer: AlohaCare Medicare	$156.50
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Devoted Health Medicare	$172.15
Rate for Payer: Hawaii Medical Service Association Medicare	$156.50
Rate for Payer: Hawaii Western Management Group Commercial	$149.55
Rate for Payer: Health Management Network Commercial	$489.60
Rate for Payer: Kaiser Permanente Commercial	$172.15
Rate for Payer: Kaiser Permanente Medicaid	$172.15
Rate for Payer: Kaiser Permanente Medicare	$172.15
Rate for Payer: Ohana Health Plan Medicaid	$174.14
Rate for Payer: Ohana Health Plan Medicare	$156.50
Rate for Payer: UnitedHealthcare Medicaid	$174.14
Rate for Payer: UnitedHealthcare Medicare	$156.50

99224 Subsequent Observation Visit, Low

Professional

Both

$101.00

Hospital Charge Code	8041029
Hospital Revenue Code	975
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$85.85
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85

99225 Subsequent Observation Visit, Moderate

Professional

Both

$181.00

Hospital Charge Code	8041030
Hospital Revenue Code	975
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$153.85
Rate for Payer: Cash Price	$117.65
Rate for Payer: Health Management Network Commercial	$153.85

99226 Subsequent Observation Visit, High

Professional

Both

$269.00

Hospital Charge Code	8041031
Hospital Revenue Code	982
Min. Negotiated Rate	$228.65
Max. Negotiated Rate	$228.65
Rate for Payer: Cash Price	$174.85
Rate for Payer: Health Management Network Commercial	$228.65

99231 Subsequent Hospital Care, Level 1

Professional

Both

$140.00

Service Code	HCPCS 99231
Hospital Charge Code	8041032
Hospital Revenue Code	975
Min. Negotiated Rate	$36.28
Max. Negotiated Rate	$119.00
Rate for Payer: AlohaCare Medicaid	$49.50
Rate for Payer: AlohaCare Medicare	$44.06
Rate for Payer: Cash Price	$91.00
Rate for Payer: Cash Price	$91.00
Rate for Payer: Devoted Health Medicare	$48.47
Rate for Payer: Hawaii Medical Service Association Medicare	$44.06
Rate for Payer: Hawaii Western Management Group Commercial	$36.28
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$48.47
Rate for Payer: Kaiser Permanente Medicaid	$48.47
Rate for Payer: Kaiser Permanente Medicare	$48.47
Rate for Payer: Ohana Health Plan Medicaid	$49.50
Rate for Payer: Ohana Health Plan Medicare	$44.06
Rate for Payer: UnitedHealthcare Medicaid	$49.50
Rate for Payer: UnitedHealthcare Medicare	$44.06

99232 Subsequent Hospital Care, Level 2

Professional

Both

$253.00

Service Code	HCPCS 99232
Hospital Charge Code	8041033
Hospital Revenue Code	975
Min. Negotiated Rate	$54.57
Max. Negotiated Rate	$215.05
Rate for Payer: AlohaCare Medicaid	$79.26
Rate for Payer: AlohaCare Medicare	$70.62
Rate for Payer: Cash Price	$164.45
Rate for Payer: Cash Price	$164.45
Rate for Payer: Devoted Health Medicare	$77.68
Rate for Payer: Hawaii Medical Service Association Medicare	$70.62
Rate for Payer: Hawaii Western Management Group Commercial	$54.57
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Kaiser Permanente Commercial	$77.68
Rate for Payer: Kaiser Permanente Medicaid	$77.68
Rate for Payer: Kaiser Permanente Medicare	$77.68
Rate for Payer: Ohana Health Plan Medicaid	$79.26
Rate for Payer: Ohana Health Plan Medicare	$70.62
Rate for Payer: UnitedHealthcare Medicaid	$79.26
Rate for Payer: UnitedHealthcare Medicare	$70.62

99233 Subsequent Hospital Care, Level 3

Professional

Both

$361.00

Service Code	HCPCS 99233
Hospital Charge Code	8041034
Hospital Revenue Code	975
Min. Negotiated Rate	$76.28
Max. Negotiated Rate	$306.85
Rate for Payer: AlohaCare Medicaid	$119.20
Rate for Payer: AlohaCare Medicare	$107.19
Rate for Payer: Cash Price	$234.65
Rate for Payer: Cash Price	$234.65
Rate for Payer: Devoted Health Medicare	$117.91
Rate for Payer: Hawaii Medical Service Association Medicare	$107.19
Rate for Payer: Hawaii Western Management Group Commercial	$76.28
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Kaiser Permanente Commercial	$117.91
Rate for Payer: Kaiser Permanente Medicaid	$117.91
Rate for Payer: Kaiser Permanente Medicare	$117.91
Rate for Payer: Ohana Health Plan Medicaid	$119.20
Rate for Payer: Ohana Health Plan Medicare	$107.19
Rate for Payer: UnitedHealthcare Medicaid	$119.20
Rate for Payer: UnitedHealthcare Medicare	$107.19

99234 Same Day Admit/Discharge, Low

Professional

Both

$381.00

Service Code	HCPCS 99234
Hospital Charge Code	8041035
Hospital Revenue Code	975
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$323.85
Rate for Payer: AlohaCare Medicaid	$97.67
Rate for Payer: AlohaCare Medicare	$87.75
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Devoted Health Medicare	$96.53
Rate for Payer: Hawaii Medical Service Association Medicare	$87.75
Rate for Payer: Hawaii Western Management Group Commercial	$70.50
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$96.53
Rate for Payer: Kaiser Permanente Medicaid	$96.53
Rate for Payer: Kaiser Permanente Medicare	$96.53
Rate for Payer: Ohana Health Plan Medicaid	$97.67
Rate for Payer: Ohana Health Plan Medicare	$87.75
Rate for Payer: UnitedHealthcare Medicaid	$97.67
Rate for Payer: UnitedHealthcare Medicare	$87.75

99235 Same Day Admit/Discharge, Moderate

Professional

Both

$535.00

Service Code	HCPCS 99235
Hospital Charge Code	8041036
Hospital Revenue Code	975
Min. Negotiated Rate	$117.50
Max. Negotiated Rate	$454.75
Rate for Payer: AlohaCare Medicaid	$160.14
Rate for Payer: AlohaCare Medicare	$143.06
Rate for Payer: Cash Price	$347.75
Rate for Payer: Cash Price	$347.75
Rate for Payer: Devoted Health Medicare	$157.37
Rate for Payer: Hawaii Medical Service Association Medicare	$143.06
Rate for Payer: Hawaii Western Management Group Commercial	$117.50
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Kaiser Permanente Commercial	$157.37
Rate for Payer: Kaiser Permanente Medicaid	$157.37
Rate for Payer: Kaiser Permanente Medicare	$157.37
Rate for Payer: Ohana Health Plan Medicaid	$160.14
Rate for Payer: Ohana Health Plan Medicare	$143.06
Rate for Payer: UnitedHealthcare Medicaid	$160.14
Rate for Payer: UnitedHealthcare Medicare	$143.06

Know your out-of-pocket cost for care.

All Charges