Prices Posted and Effective as of 12-29-2020

Wahiawa General Hospital's Price List for Shoppable Services

Prices Posted and Effective as of 12-29-2020

Disclaimer: The Hospital determines its standard charges for patient items and services through the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient’s bill. These are the baseline rates for items and services provided at the Hospital. The chargemaster is similar in concept to the manufacturer’s suggested retail price (“MSRP”) on a particular product or good. The charges listed provide only a general starting point in determining the potential costs of an individual patient’s care at the Hospital. This list does not reflect the actual out-of-pocket costs that may be paid by a patient for any particular service, it is not binding, and the actual charges for items and services may vary. Individuals with questions about their out-of-pocket costs of service and other financial information should contact the hospital or consider contacting their insurers for further information. The cost of treatment also may be impacted by variables involved in a patient’s actual care, such as specific equipment or supplies required, the length of time spent in surgery or recovery, additional tests, or any changes in care or unexpected conditions or complications that arise.

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Service DescriptionService CodeCash PriceRates
Service DescriptionService CodeCash PriceRates
CT Scan
CT scanCPT 70450$458
CT scan of abdomen and pelvis with contrastCPT 74177$2,718
CT scan of pelvis with contrastCPT 72193$1,011
Ct abd & pelv 1/> regnsCPT 74178$3,533
Ct abd & pelvis w/o contrastCPT 74176$2,091
Ct angio abd&pelv w/o&w/dyeCPT 74174$1,516
Ct angiography chestCPT 71275$1,264
Ct angiography headCPT 70496$1,011
Ct angiography neckCPT 70498$1,011
Ct chest spine w/o dyeCPT 72128$1,460
Ct lower extremity w/dyeCPT 73701$1,011
Ct lower extremity w/o dyeCPT 73700$809
Ct lumbar spine w/o dyeCPT 72131$1,460
Ct maxillofacial w/dyeCPT 70487$758
Ct maxillofacial w/o dyeCPT 70486$607
Ct neck spine w/o dyeCPT 72125$1,460
Ct pelvis w/o dyeCPT 72192$809
Ct soft tissue neck w/dyeCPT 70491$758
Ct soft tissue neck w/o dyeCPT 70490$607
Ct thorax w/dyeCPT 71260$1,264
Ct thorax w/o dyeCPT 71250$1,011
Ct upper extremity w/dyeCPT 73201$1,011
Ct upper extremity w/o dyeCPT 73200$809
Ldct for lung ca screenHCPCS G0297$248
Cardiology
Cardiovascular stress testCPT 93017$995
Tte w/doppler completeCPT 93306$2,531
Clinic
Initial new patient preventative medicine evaluation (18-3... (Not Offered)CPT 99385--
Initial new patient preventative medicine evaluation (40-6... (Not Offered)CPT 99386--
New patient office or other outpatient visit, 30 min (Not Offered)CPT 99203--
New patient office or other outpatient visit, 45 min (Not Offered)CPT 99204--
New patient office or other outpatient visit, 60 min (Not Offered)CPT 99205--
Patient office consultation, 40 min (Not Offered)CPT 99243--
Patient office consultation, 60 min (Not Offered)CPT 99244--
EEG
Eeg awake and asleepCPT 95819$995
Sleep study (Not Offered)CPT 95810--
EKG
Ecg monit/reprt up to 48 hrsCPT 93225$315
Ecg monit/reprt up to 48 hrsCPT 93226$315
Electrocardiogram tracingCPT 93005$168
Electrocardiogram, routine, with interpretation and report (Not Offered)CPT 93000--
Emergency Room
Application long leg splintCPT 29505$271
Application lower leg splintCPT 29515$271
Application of finger splintCPT 29130$168
Apply forearm splintCPT 29125$210
Apply long arm splintCPT 29105$271
Clear outer ear canalCPT 69200$210
Control of nosebleedCPT 30901$210
Critical care addl 30 minCPT 99292$260
Critical care first hourCPT 99291$3,301
Drain/inj joint/bursa w/o usCPT 20610$587
Drainage of skin abscessCPT 10060$338
Drainage of skin abscessCPT 10061$622
Dress/debrid p-thick burn sCPT 16020$338
Dx lmbr spi pnxrCPT 62270$1,630
Emergency dept visitCPT 99283$986
Emergency dept visitCPT 99284$1,600
Emergency dept visitCPT 99285$2,344
Emergency dept visitCPT 99282$561
Emergency dept visitCPT 99281$309
Heart/lung resuscitation cprCPT 92950$498
Hydrate iv infusion add-onCPT 96361$74
Hydration iv infusion initCPT 96360$382
Immunization adminCPT 90471$116
Insert emergency airwayCPT 31500$536
Insert non-tunnel cv cathCPT 36556$1,966
Insert temp bladder cathCPT 51702$210
Insertion of chest tubeCPT 32551$1,966
Mod sed same phys/qhp 5/>yrsCPT 99152$95
Njx aa&/strd other pn/branchCPT 64450$1,087
Njx aa&/strd trigeminal nrvCPT 64400$489
Puncture drainage of lesionCPT 10160$622
Removal of nail plateCPT 11730$338
Remove foreign bodyCPT 10120$622
Remove impacted ear wax uniCPT 69209$112
Rpr f/e/e/n/l/m 2.5 cm/<CPT 12011$338
Rpr f/e/e/n/l/m 2.6-5.0 cmCPT 12013$338
Rpr s/n/ax/gen/trk7.6-12.5cmCPT 12004$338
Rpr s/n/ax/gen/trnk 2.5cm/<CPT 12001$338
Rpr s/n/ax/gen/trnk2.6-7.5cmCPT 12002$338
Treat elbow dislocationCPT 24640$430
Treat fracture radius/ulnaCPT 25605$1,350
Treat shoulder dislocationCPT 23650$430
Imaging
Abdomial ultrasound of pregnant uterusCPT 76805$458
Breast tomosynthesis biCPT 77063$44
Breast tomosynthesis biCPT 77062$67
Breast tomosynthesis uniCPT 77061$44
Bx breast 1st lesion us imagCPT 19083$2,696
Echo exam of abdomenCPT 76705$458
Echo guide for biopsyCPT 76942$852
Mammography of both breastsCPT 77066$678
Mammography of one breastCPT 77065$539
Mammography, screening, bilateralCPT 77067$583
Ob us < 14 wks single fetusCPT 76801$458
Ob us limited fetus(s)CPT 76815$229
Transvaginal us obstetricCPT 76817$458
Ultrasound breast completeCPT 76641$229
Ultrasound breast limitedCPT 76642$124
Ultrasound of abdomenCPT 76700$572
Ultrasound pelvis through vaginaCPT 76830$343
Us abdl aorta screen aaaCPT 76706$229
Us exam abdo back wall compCPT 76770$572
Us exam abdo back wall limCPT 76775$458
Us exam of head and neckCPT 76536$343
Us exam pelvic completeCPT 76856$343
Us exam scrotumCPT 76870$229
Us guide vascular accessCPT 76937$245
Us lmtd jt/nonvasc xtr struxCPT 76882$229
Inpatient Procedures
Cardiac valve or cardiothoracic procedure with cardiac cat... (Not Offered)DRG 216--
Cervical spinal fusion without CC or MCC (Not Offered)DRG 473--
Major joint replacement or reattachment of lower extremity... (Not Offered)DRG 470--
Spinal fusion except cervical without MCC (Not Offered)DRG 460--
Uterine and adnexa procedures for non-malignancy without C... (Not Offered)DRG 743--
Laboratory
Acute hepatitis panelCPT 80074$294
Ag detect nos ia multCPT 87449$74
Alpha-fetoprotein serumCPT 82105$104
Antinuclear antibodiesCPT 86038$75
Antistreptolysin o titerCPT 86060$45
Assay dipropylacetic acd totCPT 80164$84
Assay glucose blood quantCPT 82947$24
Assay of ammoniaCPT 82140$90
Assay of amylaseCPT 82150$40
Assay of blood lipoproteinCPT 83721$59
Assay of blood osmolalityCPT 83930$41
Assay of blood/uric acidCPT 84550$28
Assay of ck (cpk)CPT 82550$80
Assay of creatinineCPT 82565$32
Assay of digoxin totalCPT 80162$82
Assay of ferritinCPT 82728$84
Assay of folic acid serumCPT 82746$91
Assay of free thyroxineCPT 84439$56
Assay of ironCPT 83540$40
Assay of lactic acidCPT 83605$106
Assay of lipaseCPT 83690$68
Assay of lithiumCPT 80178$41
Assay of magnesiumCPT 83735$66
Assay of natriuretic peptideCPT 83880$210
Assay of phenytoin totalCPT 80185$82
Assay of phosphorusCPT 84100$47
Assay of prealbuminCPT 84134$90
Assay of protein otherCPT 84157$23
Assay of protein serumCPT 84155$23
Assay of protein urineCPT 84156$23
Assay of serum albuminCPT 82040$31
Assay of serum potassiumCPT 84132$28
Assay of serum sodiumCPT 84295$30
Assay of triglyceridesCPT 84478$35
Assay of urine creatinineCPT 82570$32
Assay of urine osmolalityCPT 83935$42
Assay of urine sodiumCPT 84300$30
Assay of vancomycinCPT 80202$84
Assay of vitamin b-1CPT 84425$131
Assay ph body fluid nosCPT 83986$22
Assay triiodothyronine (t3)CPT 84480$88
Automated platelet countCPT 85049$28
Basic metabolic panelCPT 80048$84
Bilirubin directCPT 82248$31
Bilirubin totalCPT 82247$31
Bl draw <3 yrs other veinCPT 36406$24
Blood culture for bacteriaCPT 87040$64
Blood gases any combinationCPT 82803$130
Blood test, clotting timeCPT 85610$39
Blood test, comprehensive group of blood chemicalsCPT 80053$104
Blood test, lipidsCPT 80061$83
Blood test, thyroid stimulating hormone (TSH)CPT 84443$104
Blood type antigen donor eaCPT 86902$431
Blood typing serologic aboCPT 86900$525
Blood typing serologic rh(d)CPT 86901$159
Body fluid cell countCPT 89051$34
C diff amplified probeCPT 87493$217
C-reactive proteinCPT 86140$32
Carcinoembryonic antigenCPT 82378$117
Chorionic gonadotropin assayCPT 84703$46
Chorionic gonadotropin testCPT 84702$93
Chylmd trach dna amp probeCPT 87491$217
Coagulation assessment blood testCPT 85730$37
Compatibility test antiglobCPT 86922$646
Compatibility test spinCPT 86920$646
Complete blood cell count (CBC), automatedCPT 85027$80
Complete blood cell count (CBC), with differential white b...CPT 85025$96
Creatine mb fractionCPT 82553$114
Cultr bacteria except bloodCPT 87075$58
Culture aerobic identifyCPT 87077$50
Culture othr specimn aerobicCPT 87070$53
Culture screen onlyCPT 87081$41
Culture type immunologicCPT 87147$32
Detect agent nos dna ampCPT 87798$117
Drug screen quantalcoholsCPT 80320$167
Drug scrn quan levetiracetamCPT 80177$82
Exam synovial fluid crystalsCPT 89060$44
Feces culture aerobic bactCPT 87045$58
Fibrin degradation quantCPT 85379$63
Glucose other fluidCPT 82945$24
Glycosylated hemoglobin testCPT 83036$60
HematocritCPT 85014$15
HemoglobinCPT 85018$15
Hep b surface antibodyCPT 86706$66
Hepatitis b surface ag iaCPT 87340$64
Hepatitis c ab testCPT 86803$88
Heterophile antibody screenCPT 86308$32
Hiv-1 ag w/hiv-1 & hiv-2 abCPT 87389$149
Hsv dna amp probeCPT 87529$117
Immunoassay quant nos nonabCPT 83520$86
Immunoassay tumor ca 19-9CPT 86301$129
Influenza assay w/opticCPT 87804$83
Influenza dna amp probeCPT 87502$315
Iron binding testCPT 83550$54
Kidney function panel testCPT 80069$54
Lactate (ld) (ldh) enzymeCPT 83615$37
Leukocyte assessment fecalCPT 89055$26
Liver function blood testCPT 80076$50
Manual reticulocyte countCPT 85044$27
Microbe susceptible micCPT 87186$53
Mumps antibodyCPT 86735$81
Mycobacteria cultureCPT 87116$67
N.gonorrhoeae dna amp probCPT 87591$217
Obstetric blood test panel (Not Offered)CPT 80055--
Occult bld feces 1-3 testsCPT 82272$21
Other source albumin quan eaCPT 82042$39
Ova and parasites smearsCPT 87177$55
Protein e-phoresis serumCPT 84165$66
Protein e-phoresis/urine/csfCPT 84166$110
Rbc antibody screenCPT 86850$224
Rbc sed rate nonautomatedCPT 85651$22
Rheumatoid factor quantCPT 86431$35
Routine venipunctureCPT 36415$24
Rubella antibodyCPT 86762$89
Rubeola antibodyCPT 86765$80
Smear complex stainCPT 87209$111
Smear fluorescent/acid staiCPT 87206$33
Smear gram stainCPT 87205$26
Smear wet mount saline/inkCPT 87210$29
Specimen infect agnt concntjCPT 87015$41
Strep a assay w/opticCPT 87880$83
Strep a dna amp probeCPT 87651$117
Syphilis test non-trep qualCPT 86592$26
Tissue exam by pathologistCPT 88305$224
Tissue exam by pathologistCPT 88304$224
Total cortisolCPT 82533$101
Total prostate-specific antigen (PSA) testCPT 84153$114
Total prostate-specific antigen (PSA) testCPT 84153$114
Total prostate-specific antigen (PSA) test (Not Offered)CPT 84154--
Ur albumin quantitativeCPT 82043$36
Urinalysis testCPT 81003$14
Urinalysis testCPT 81002$17
Urinalysis test using microscopeCPT 81001$39
Urinalysis test using microscope (Not Offered)CPT 81000--
Urine bacteria cultureCPT 87088$50
Urine culture/colony countCPT 87086$50
Urine pregnancy testCPT 81025$43
Varicella-zoster antibodyCPT 86787$80
Vitamin b-12CPT 82607$93
Vitamin d 25 hydroxyCPT 82306$183
Wbc antibody identificationCPT 86021$74
Language Pathology
Evaluate swallowing functionCPT 92610$586
Motion fluoroscopy/swallowCPT 92611$379
Oral function therapyCPT 92526$284
Speech sound lang comprehenCPT 92523$367
Speech/hearing therapyCPT 92507$91
MRI
MRI Scan (Not Offered)CPT 70553--
MRI scan of leg joint (Not Offered)CPT 73721--
MRI scan of lower spinal canal (Not Offered)CPT 72148--
Medical and Surgical Supplies
BLANKET BAIR HUGGER LOWER BODYHCPCS E0215$21
Cath impl vasc access portalHCPCS A4300$287
Cath insertion tray w/bagHCPCS A4354$27
Cath w/drainage 2-way latexHCPCS A4314$41
Foam drg <=16 sq in w/borderHCPCS A6212$20
Infusion supplies with pumpHCPCS A4222$23
Special supplies phys/qhpCPT 99070$98
Sterile water/saline, 500 mlHCPCS A4217$7
Surgical suppliesHCPCS A4649$25
Transparent film <= 16 sq inHCPCS A6257$19
Nuclear Medicine
Hepatobil syst image w/drugCPT 78227$1,359
Hepatobiliary system imagingCPT 78226$1,048
Ht muscle image spect multCPT 78452$3,608
Lung ventilat&perfus imagingCPT 78582$1,359
Tc99m maaHCPCS A9540$119
Tc99m mebrofeninHCPCS A9537$84
Tc99m medronateHCPCS A9503$81
Tc99m pertechnetateHCPCS A9512$4
Tc99m sestamibiHCPCS A9500$223
Technetium tc-99m aerosolHCPCS A9567$91
Other Diagnostic
Extracranial bilat studyCPT 93880$697
Extremity studyCPT 93970$697
Extremity studyCPT 93971$343
Lower extremity studyCPT 93925$697
Vascular studyCPT 93976$229
Other Procedures and Observation
Withdrawal of arterial bloodCPT 36600$210
Other Therapeutic
Blood transfusion serviceCPT 36430$1,126
Plasma 1 donor frz w/in 8 hrHCPCS P9017$121
Plasma fresh frozenCPT 86927$1,078
Rbc leukocytes reducedHCPCS P9016$294
Ther/diag concurrent infCPT 96368$343
Ther/proph/diag inj iv pushCPT 96374$287
Ther/proph/diag inj sc/imCPT 96372$116
Ther/proph/diag iv inf addonCPT 96366$191
Ther/proph/diag iv inf initCPT 96365$382
Tx/pro/dx inj new drug addonCPT 96375$191
Tx/pro/dx inj same drug adonCPT 96376$191
Tx/proph/dg addl seq iv infCPT 96367$343
Psychiatric
Family psychotherapy, including patient, 50 min (Not Offered)CPT 90847--
Family psychotherapy, not including patient, 50 min (Not Offered)CPT 90846--
Group psychotherapy (Not Offered)CPT 90853--
Psychotherapy, 30 min (Not Offered)CPT 90832--
Psychotherapy, 45 min (Not Offered)CPT 90834--
Psychotherapy, 60 min (Not Offered)CPT 90837--
Pulmonary Function
Evaluation of wheezingCPT 94060$747
Measure blood oxygen levelCPT 94761$444
Radiology
Dxa bone density axialCPT 77080$343
Fluoroguide for vein deviceCPT 77001$304
Fluoroscopy <1 hr phys/qhpCPT 76000$697
X-Ray of lower backCPT 72110$412
X-ray exam abdomen 1 viewCPT 74018$186
X-ray exam abdomen 3+ viewsCPT 74021$343
X-ray exam chest 1 viewCPT 71045$187
X-ray exam chest 2 viewsCPT 71046$224
X-ray exam complete abdomenCPT 74022$412
X-ray exam hip uni 1 viewCPT 73501$186
X-ray exam hip uni 2-3 viewsCPT 73502$280
X-ray exam hips bi 2 viewsCPT 73521$343
X-ray exam knee 4 or moreCPT 73564$268
X-ray exam l-s spine 2/3 vwsCPT 72100$343
X-ray exam l-s spine bendingCPT 72114$412
X-ray exam neck spine 2-3 vwCPT 72040$224
X-ray exam neck spine 4/5vwsCPT 72050$343
X-ray exam neck spine 6/>vwsCPT 72052$343
X-ray exam of ankleCPT 73610$280
X-ray exam of ankleCPT 73600$186
X-ray exam of collar boneCPT 73000$186
X-ray exam of elbowCPT 73080$280
X-ray exam of femur 2/>CPT 73552$186
X-ray exam of finger(s)CPT 73140$186
X-ray exam of footCPT 73630$280
X-ray exam of footCPT 73620$186
X-ray exam of forearmCPT 73090$186
X-ray exam of handCPT 73130$412
X-ray exam of handCPT 73120$343
X-ray exam of heelCPT 73650$186
X-ray exam of humerusCPT 73060$186
X-ray exam of knee 1 or 2CPT 73560$186
X-ray exam of knee 3CPT 73562$224
X-ray exam of lower legCPT 73590$186
X-ray exam of nasal bonesCPT 70160$186
X-ray exam of neckCPT 70360$186
X-ray exam of pelvisCPT 72170$343
X-ray exam of pelvisCPT 72190$515
X-ray exam of shoulderCPT 73030$280
X-ray exam of toe(s)CPT 73660$186
X-ray exam of wristCPT 73110$280
X-ray exam of wristCPT 73100$186
X-ray exam ribs uni 2 viewsCPT 71100$186
X-ray exam sacrum tailboneCPT 72220$186
X-ray exam thorac spine 2vwsCPT 72070$343
X-ray exam thorac spine 3vwsCPT 72072$412
X-ray exam unilat ribs/chestCPT 71101$343
X-ray nose to rectumCPT 76010$186
X-ray xm esophagus 1cntrstCPT 74220$758
X-ray xm sm int 1cntrst stdCPT 74250$458
X-ray xm swlng funcj c+CPT 74230$343
Respiratory
Airway inhalation treatmentCPT 94640$373
Cbt 1st hourCPT 94644$210
Chest wall manipulationCPT 94668$210
Pos airway pressure cpapCPT 94660$1,118
Vent mgmt inpat init dayCPT 94002$2,073
Vent mgmt inpat subq dayCPT 94003$2,073
Surgical Procedures
Abd paracentesis w/imagingCPT 49083$1,487
Aspirate pleura w/ imagingCPT 32555$1,225
Biopsy exam of esophagus, stomach or small bowel using an ...CPT 43239$439
Biopsy exam of large bowel using an endoscope (Not Offered)CPT 45380--
Biopsy of prostate gland (Not Offered)CPT 55700--
Diagnostic exam of esophagus, stomach or small bowel using... (Not Offered)CPT 43235--
Diagnostic exam of large bowel using an endoscopeCPT 45378$439
Injection(s) of anesthetic into lower spine using imaging ... (Not Offered)CPT 64483--
Injection(s) of therapeutic substance (Not Offered)CPT 62322--
Injection(s) of therapeutic substance (Not Offered)CPT 62323--
Insertion of catheter into left heart for diagnosis (Not Offered)CPT 93542--
Insj picc rs&i 5 yr+CPT 36573$2,949
Obstetric care, planned cesarean delivery (Not Offered)CPT 59510--
Obstetric care, planned vaginal delivery (Not Offered)CPT 59400--
Obstetric care, planned vaginal delivery (post delivery by... (Not Offered)CPT 59610--
Removal of cataract with insertion of lens (Not Offered)CPT 66984--
Removal of gallbladder using an endoscope (Not Offered)CPT 47562--
Removal of one knee cartilage using an endoscope (Not Offered)CPT 29881--
Removal of one or more breast growth, open procedure (Not Offered)CPT 19120--
Removal of polyps or growths of large bowel using an endos...CPT 45385$840
Removal of recurring cataract in lens capsule using laser (Not Offered)CPT 66821--
Removal of tonsils and adenoid glands, patient younger tha... (Not Offered)CPT 42820--
Repair of groin hernia patient age 5 years or older (Not Offered)CPT 49505--
Shaving of shoulder bone using endoscope (Not Offered)CPT 29826--
Surgical removal of prostate and surrounding lymph nodes u... (Not Offered)CPT 55866--
Ultrasound examination of lower large bowel using an endos... (Not Offered)CPT 45391--
Therapy
Gait training therapyCPT 97116$98
Manual therapy 1/> regionsCPT 97140$90
Neuromuscular reeducationCPT 97112$114
Orthotic mgmt&traing 1st encCPT 97760$156
Ot eval low complex 30 minCPT 97165$296
Ot eval mod complex 45 minCPT 97166$296
Physical therapy, therapeutic exerciseCPT 97110$99
Physical therapy, therapeutic exerciseCPT 97110$99
Pt eval low complex 20 minCPT 97161$401
Pt eval mod complex 30 minCPT 97162$364
Pt re-eval est plan careCPT 97164$186
Self care mngment trainingCPT 97535$113
Therapeutic activitiesCPT 97530$134
Wheelchair mngment trainingCPT 97542$109
Uncategorized
Admin influenza virus vacHCPCS G0008$74
Admin pneumococcal vaccineHCPCS G0009$74
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