Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Ammonia FSI

Facility

$185.00

Service Code	HCPCS 82140
Hospital Charge Code	8117838
Hospital Revenue Code	301
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$92.50
Rate for Payer: AlohaCare Medicare	$92.50
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$101.75
Rate for Payer: Hawaii Medical Service Association ABD	$20.14
Rate for Payer: Hawaii Medical Service Association Commercial	$18.21
Rate for Payer: Hawaii Medical Service Association Medicare	$92.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.15
Rate for Payer: Hawaii Western Management Group Commercial	$14.57
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$92.50
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$92.50
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$92.50
Rate for Payer: Ohana Health Plan Medicare	$92.50
Rate for Payer: UnitedHealthcare Medicaid	$20.14
Rate for Payer: UnitedHealthcare Medicare	$92.50
Rate for Payer: University Health Alliance Commercial	$37.67

Ammonia FSI

Facility

$185.00

Service Code	HCPCS 82140
Hospital Charge Code	8117838
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: MDX Hawaii PPO	$179.45

Amnisure FSI

Facility

$210.00

Service Code	HCPCS 84112
Hospital Charge Code	11188880
Hospital Revenue Code	301
Min. Negotiated Rate	$86.99
Max. Negotiated Rate	$203.70
Rate for Payer: AlohaCare Medicaid	$105.00
Rate for Payer: AlohaCare Medicare	$105.00
Rate for Payer: Cash Price	$136.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Devoted Health Medicare	$115.50
Rate for Payer: Hawaii Medical Service Association ABD	$90.64
Rate for Payer: Hawaii Medical Service Association Commercial	$122.64
Rate for Payer: Hawaii Medical Service Association Medicare	$105.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$86.99
Rate for Payer: Hawaii Western Management Group Commercial	$98.11
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Humana Medicare	$105.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$107.10
Rate for Payer: Kaiser Permanente Medicare	$105.00
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: Ohana Health Plan Medicaid	$105.00
Rate for Payer: Ohana Health Plan Medicare	$105.00
Rate for Payer: UnitedHealthcare Medicaid	$90.64
Rate for Payer: UnitedHealthcare Medicare	$105.00
Rate for Payer: University Health Alliance Commercial	$167.68

Amnisure FSI

Facility

$210.00

Service Code	HCPCS 84112
Hospital Charge Code	11188880
Hospital Revenue Code	301
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$136.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: MDX Hawaii PPO	$203.70

amoxicillin 400 mg/5 ml 100ml [HHSC]

Facility

$57.45

Service Code	NDC 00781615746
Hospital Charge Code	2500054
Hospital Revenue Code	250
Min. Negotiated Rate	$28.73
Max. Negotiated Rate	$55.73
Rate for Payer: AlohaCare Medicaid	$28.73
Rate for Payer: AlohaCare Medicare	$28.73
Rate for Payer: Cash Price	$37.34
Rate for Payer: Devoted Health Medicare	$31.60
Rate for Payer: Hawaii Medical Service Association Medicare	$28.73
Rate for Payer: Hawaii Western Management Group Commercial	$54.58
Rate for Payer: Health Management Network Commercial	$48.83
Rate for Payer: Humana Medicare	$28.73
Rate for Payer: Kaiser Permanente Commercial	$51.70
Rate for Payer: Kaiser Permanente Medicaid	$29.30
Rate for Payer: Kaiser Permanente Medicare	$28.73
Rate for Payer: MDX Hawaii PPO	$55.73
Rate for Payer: Ohana Health Plan Medicaid	$28.73
Rate for Payer: Ohana Health Plan Medicare	$28.73
Rate for Payer: UnitedHealthcare Medicaid	$34.47
Rate for Payer: UnitedHealthcare Medicare	$28.73
Rate for Payer: University Health Alliance Commercial	$41.88

amoxicillin 400 mg/5 ml 100ml [HHSC]

Facility

$57.45

Service Code	NDC 00781615746
Hospital Charge Code	2500054
Hospital Revenue Code	250
Min. Negotiated Rate	$48.83
Max. Negotiated Rate	$55.73
Rate for Payer: Cash Price	$37.34
Rate for Payer: Health Management Network Commercial	$48.83
Rate for Payer: Kaiser Permanente Commercial	$51.70
Rate for Payer: MDX Hawaii PPO	$55.73

amoxicillin 400 mg/5 ml 100ml [HHSC]

Facility

$57.45

Service Code	NDC 00143988701
Hospital Charge Code	2500054
Hospital Revenue Code	250
Min. Negotiated Rate	$28.73
Max. Negotiated Rate	$55.73
Rate for Payer: AlohaCare Medicaid	$28.73
Rate for Payer: AlohaCare Medicare	$28.73
Rate for Payer: Cash Price	$37.34
Rate for Payer: Devoted Health Medicare	$31.60
Rate for Payer: Hawaii Medical Service Association Medicare	$28.73
Rate for Payer: Hawaii Western Management Group Commercial	$54.58
Rate for Payer: Health Management Network Commercial	$48.83
Rate for Payer: Humana Medicare	$28.73
Rate for Payer: Kaiser Permanente Commercial	$51.70
Rate for Payer: Kaiser Permanente Medicaid	$29.30
Rate for Payer: Kaiser Permanente Medicare	$28.73
Rate for Payer: MDX Hawaii PPO	$55.73
Rate for Payer: Ohana Health Plan Medicaid	$28.73
Rate for Payer: Ohana Health Plan Medicare	$28.73
Rate for Payer: UnitedHealthcare Medicaid	$34.47
Rate for Payer: UnitedHealthcare Medicare	$28.73
Rate for Payer: University Health Alliance Commercial	$41.88

amoxicillin 400 mg/5 ml 100ml [HHSC]

Facility

$57.45

Service Code	NDC 00143988701
Hospital Charge Code	2500054
Hospital Revenue Code	250
Min. Negotiated Rate	$48.83
Max. Negotiated Rate	$55.73
Rate for Payer: Cash Price	$37.34
Rate for Payer: Health Management Network Commercial	$48.83
Rate for Payer: Kaiser Permanente Commercial	$51.70
Rate for Payer: MDX Hawaii PPO	$55.73

amoxicillin 400 mg/5 ml 100ml [HHSC]

Facility

$57.45

Service Code	NDC 65862007101
Hospital Charge Code	2500054
Hospital Revenue Code	250
Min. Negotiated Rate	$28.73
Max. Negotiated Rate	$55.73
Rate for Payer: AlohaCare Medicaid	$28.73
Rate for Payer: AlohaCare Medicare	$28.73
Rate for Payer: Cash Price	$37.34
Rate for Payer: Devoted Health Medicare	$31.60
Rate for Payer: Hawaii Medical Service Association Medicare	$28.73
Rate for Payer: Hawaii Western Management Group Commercial	$54.58
Rate for Payer: Health Management Network Commercial	$48.83
Rate for Payer: Humana Medicare	$28.73
Rate for Payer: Kaiser Permanente Commercial	$51.70
Rate for Payer: Kaiser Permanente Medicaid	$29.30
Rate for Payer: Kaiser Permanente Medicare	$28.73
Rate for Payer: MDX Hawaii PPO	$55.73
Rate for Payer: Ohana Health Plan Medicaid	$28.73
Rate for Payer: Ohana Health Plan Medicare	$28.73
Rate for Payer: UnitedHealthcare Medicaid	$34.47
Rate for Payer: UnitedHealthcare Medicare	$28.73
Rate for Payer: University Health Alliance Commercial	$41.88

amoxicillin 400 mg/5 ml 100ml [HHSC]

Facility

$57.45

Service Code	NDC 65862007101
Hospital Charge Code	2500054
Hospital Revenue Code	250
Min. Negotiated Rate	$48.83
Max. Negotiated Rate	$55.73
Rate for Payer: Cash Price	$37.34
Rate for Payer: Health Management Network Commercial	$48.83
Rate for Payer: Kaiser Permanente Commercial	$51.70
Rate for Payer: MDX Hawaii PPO	$55.73

amoxicillin 500 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00781261301
Hospital Charge Code	2500055
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

amoxicillin 500 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00781261301
Hospital Charge Code	2500055
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

amoxicillin/clav 250 mg/5 ml 100 mL [HHSC]

Facility

$545.38

Service Code	NDC 43598020452
Hospital Charge Code	2500056
Hospital Revenue Code	250
Min. Negotiated Rate	$463.57
Max. Negotiated Rate	$529.02
Rate for Payer: Cash Price	$354.50
Rate for Payer: Health Management Network Commercial	$463.57
Rate for Payer: Kaiser Permanente Commercial	$490.84
Rate for Payer: MDX Hawaii PPO	$529.02

amoxicillin/clav 250 mg/5 ml 100 mL [HHSC]

Facility

$401.21

Service Code	NDC 59651002601
Hospital Charge Code	2500056
Hospital Revenue Code	250
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$389.17
Rate for Payer: AlohaCare Medicaid	$200.60
Rate for Payer: AlohaCare Medicare	$200.60
Rate for Payer: Cash Price	$260.79
Rate for Payer: Devoted Health Medicare	$220.67
Rate for Payer: Hawaii Medical Service Association Medicare	$200.60
Rate for Payer: Hawaii Western Management Group Commercial	$381.15
Rate for Payer: Health Management Network Commercial	$341.03
Rate for Payer: Humana Medicare	$200.60
Rate for Payer: Kaiser Permanente Commercial	$361.09
Rate for Payer: Kaiser Permanente Medicaid	$204.62
Rate for Payer: Kaiser Permanente Medicare	$200.60
Rate for Payer: MDX Hawaii PPO	$389.17
Rate for Payer: Ohana Health Plan Medicaid	$200.60
Rate for Payer: Ohana Health Plan Medicare	$200.60
Rate for Payer: UnitedHealthcare Medicaid	$240.73
Rate for Payer: UnitedHealthcare Medicare	$200.60
Rate for Payer: University Health Alliance Commercial	$292.44

amoxicillin/clav 250 mg/5 ml 100 mL [HHSC]

Facility

$401.21

Service Code	NDC 59651002601
Hospital Charge Code	2500056
Hospital Revenue Code	250
Min. Negotiated Rate	$341.03
Max. Negotiated Rate	$389.17
Rate for Payer: Cash Price	$260.79
Rate for Payer: Health Management Network Commercial	$341.03
Rate for Payer: Kaiser Permanente Commercial	$361.09
Rate for Payer: MDX Hawaii PPO	$389.17

amoxicillin/clav 250 mg/5 ml 100 mL [HHSC]

Facility

$401.21

Service Code	NDC 60432006500
Hospital Charge Code	2500056
Hospital Revenue Code	250
Min. Negotiated Rate	$341.03
Max. Negotiated Rate	$389.17
Rate for Payer: Cash Price	$260.79
Rate for Payer: Health Management Network Commercial	$341.03
Rate for Payer: Kaiser Permanente Commercial	$361.09
Rate for Payer: MDX Hawaii PPO	$389.17

amoxicillin/clav 250 mg/5 ml 100 mL [HHSC]

Facility

$401.21

Service Code	NDC 60432006500
Hospital Charge Code	2500056
Hospital Revenue Code	250
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$389.17
Rate for Payer: AlohaCare Medicaid	$200.60
Rate for Payer: AlohaCare Medicare	$200.60
Rate for Payer: Cash Price	$260.79
Rate for Payer: Devoted Health Medicare	$220.67
Rate for Payer: Hawaii Medical Service Association Medicare	$200.60
Rate for Payer: Hawaii Western Management Group Commercial	$381.15
Rate for Payer: Health Management Network Commercial	$341.03
Rate for Payer: Humana Medicare	$200.60
Rate for Payer: Kaiser Permanente Commercial	$361.09
Rate for Payer: Kaiser Permanente Medicaid	$204.62
Rate for Payer: Kaiser Permanente Medicare	$200.60
Rate for Payer: MDX Hawaii PPO	$389.17
Rate for Payer: Ohana Health Plan Medicaid	$200.60
Rate for Payer: Ohana Health Plan Medicare	$200.60
Rate for Payer: UnitedHealthcare Medicaid	$240.73
Rate for Payer: UnitedHealthcare Medicare	$200.60
Rate for Payer: University Health Alliance Commercial	$292.44

amoxicillin/clav 250 mg/5 ml 100 mL [HHSC]

Facility

$545.38

Service Code	NDC 43598020452
Hospital Charge Code	2500056
Hospital Revenue Code	250
Min. Negotiated Rate	$272.69
Max. Negotiated Rate	$529.02
Rate for Payer: AlohaCare Medicaid	$272.69
Rate for Payer: AlohaCare Medicare	$272.69
Rate for Payer: Cash Price	$354.50
Rate for Payer: Devoted Health Medicare	$299.96
Rate for Payer: Hawaii Medical Service Association Medicare	$272.69
Rate for Payer: Hawaii Western Management Group Commercial	$518.11
Rate for Payer: Health Management Network Commercial	$463.57
Rate for Payer: Humana Medicare	$272.69
Rate for Payer: Kaiser Permanente Commercial	$490.84
Rate for Payer: Kaiser Permanente Medicaid	$278.14
Rate for Payer: Kaiser Permanente Medicare	$272.69
Rate for Payer: MDX Hawaii PPO	$529.02
Rate for Payer: Ohana Health Plan Medicaid	$272.69
Rate for Payer: Ohana Health Plan Medicare	$272.69
Rate for Payer: UnitedHealthcare Medicaid	$327.23
Rate for Payer: UnitedHealthcare Medicare	$272.69
Rate for Payer: University Health Alliance Commercial	$397.53

amoxicillin-clav 875 mg tablet [HHSC]

Facility

$28.09

Service Code	NDC 65862050320
Hospital Charge Code	2500058
Hospital Revenue Code	250
Min. Negotiated Rate	$23.88
Max. Negotiated Rate	$27.25
Rate for Payer: Cash Price	$18.26
Rate for Payer: Health Management Network Commercial	$23.88
Rate for Payer: Kaiser Permanente Commercial	$25.28
Rate for Payer: MDX Hawaii PPO	$27.25

amoxicillin-clav 875 mg tablet [HHSC]

Facility

$27.24

Service Code	NDC 66685100101
Hospital Charge Code	2500058
Hospital Revenue Code	250
Min. Negotiated Rate	$23.15
Max. Negotiated Rate	$26.42
Rate for Payer: Cash Price	$17.71
Rate for Payer: Health Management Network Commercial	$23.15
Rate for Payer: Kaiser Permanente Commercial	$24.52
Rate for Payer: MDX Hawaii PPO	$26.42

amoxicillin-clav 875 mg tablet [HHSC]

Facility

$27.24

Service Code	NDC 66685100101
Hospital Charge Code	2500058
Hospital Revenue Code	250
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$26.42
Rate for Payer: AlohaCare Medicaid	$13.62
Rate for Payer: AlohaCare Medicare	$13.62
Rate for Payer: Cash Price	$17.71
Rate for Payer: Devoted Health Medicare	$14.98
Rate for Payer: Hawaii Medical Service Association Medicare	$13.62
Rate for Payer: Hawaii Western Management Group Commercial	$25.88
Rate for Payer: Health Management Network Commercial	$23.15
Rate for Payer: Humana Medicare	$13.62
Rate for Payer: Kaiser Permanente Commercial	$24.52
Rate for Payer: Kaiser Permanente Medicaid	$13.89
Rate for Payer: Kaiser Permanente Medicare	$13.62
Rate for Payer: MDX Hawaii PPO	$26.42
Rate for Payer: Ohana Health Plan Medicaid	$13.62
Rate for Payer: Ohana Health Plan Medicare	$13.62
Rate for Payer: UnitedHealthcare Medicaid	$16.34
Rate for Payer: UnitedHealthcare Medicare	$13.62
Rate for Payer: University Health Alliance Commercial	$19.86

amoxicillin-clav 875 mg tablet [HHSC]

Facility

$28.09

Service Code	NDC 65862050320
Hospital Charge Code	2500058
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.25
Rate for Payer: AlohaCare Medicaid	$14.04
Rate for Payer: AlohaCare Medicare	$14.04
Rate for Payer: Cash Price	$18.26
Rate for Payer: Devoted Health Medicare	$15.45
Rate for Payer: Hawaii Medical Service Association Medicare	$14.04
Rate for Payer: Hawaii Western Management Group Commercial	$26.69
Rate for Payer: Health Management Network Commercial	$23.88
Rate for Payer: Humana Medicare	$14.04
Rate for Payer: Kaiser Permanente Commercial	$25.28
Rate for Payer: Kaiser Permanente Medicaid	$14.33
Rate for Payer: Kaiser Permanente Medicare	$14.04
Rate for Payer: MDX Hawaii PPO	$27.25
Rate for Payer: Ohana Health Plan Medicaid	$14.04
Rate for Payer: Ohana Health Plan Medicare	$14.04
Rate for Payer: UnitedHealthcare Medicaid	$16.85
Rate for Payer: UnitedHealthcare Medicare	$14.04
Rate for Payer: University Health Alliance Commercial	$20.47

amoxicillin-clav 875 mg tablet [HHSC]

Facility

$11.26

Service Code	NDC 00093227534
Hospital Charge Code	2500058
Hospital Revenue Code	250
Min. Negotiated Rate	$9.57
Max. Negotiated Rate	$10.92
Rate for Payer: Cash Price	$7.32
Rate for Payer: Health Management Network Commercial	$9.57
Rate for Payer: Kaiser Permanente Commercial	$10.13
Rate for Payer: MDX Hawaii PPO	$10.92

amoxicillin-clav 875 mg tablet [HHSC]

Facility

$11.26

Service Code	NDC 00093227534
Hospital Charge Code	2500058
Hospital Revenue Code	250
Min. Negotiated Rate	$5.63
Max. Negotiated Rate	$10.92
Rate for Payer: AlohaCare Medicaid	$5.63
Rate for Payer: AlohaCare Medicare	$5.63
Rate for Payer: Cash Price	$7.32
Rate for Payer: Devoted Health Medicare	$6.19
Rate for Payer: Hawaii Medical Service Association Medicare	$5.63
Rate for Payer: Hawaii Western Management Group Commercial	$10.70
Rate for Payer: Health Management Network Commercial	$9.57
Rate for Payer: Humana Medicare	$5.63
Rate for Payer: Kaiser Permanente Commercial	$10.13
Rate for Payer: Kaiser Permanente Medicaid	$5.74
Rate for Payer: Kaiser Permanente Medicare	$5.63
Rate for Payer: MDX Hawaii PPO	$10.92
Rate for Payer: Ohana Health Plan Medicaid	$5.63
Rate for Payer: Ohana Health Plan Medicare	$5.63
Rate for Payer: UnitedHealthcare Medicaid	$6.76
Rate for Payer: UnitedHealthcare Medicare	$5.63
Rate for Payer: University Health Alliance Commercial	$8.21

amoxicillin-clav 875 mg tablet [HHSC]

Facility

$28.09

Service Code	NDC 00781185220
Hospital Charge Code	2500058
Hospital Revenue Code	250
Min. Negotiated Rate	$23.88
Max. Negotiated Rate	$27.25
Rate for Payer: Cash Price	$18.26
Rate for Payer: Health Management Network Commercial	$23.88
Rate for Payer: Kaiser Permanente Commercial	$25.28
Rate for Payer: MDX Hawaii PPO	$27.25

Know your out-of-pocket cost for care.

All Charges