Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Anti-Thyroglobulin and Anti-Thyroid Peroxidase Antibody FSI

Facility

$183.00

Service Code	HCPCS 86800
Hospital Charge Code	8117851
Hospital Revenue Code	302
Min. Negotiated Rate	$15.91
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$91.50
Rate for Payer: Cash Price	$118.95
Rate for Payer: Cash Price	$118.95
Rate for Payer: Devoted Health Medicare	$100.65
Rate for Payer: Hawaii Medical Service Association ABD	$21.98
Rate for Payer: Hawaii Medical Service Association Commercial	$19.89
Rate for Payer: Hawaii Medical Service Association Medicare	$91.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.08
Rate for Payer: Hawaii Western Management Group Commercial	$15.91
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$91.50
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$91.50
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$91.50
Rate for Payer: Ohana Health Plan Medicare	$91.50
Rate for Payer: UnitedHealthcare Medicaid	$21.98
Rate for Payer: UnitedHealthcare Medicare	$91.50
Rate for Payer: University Health Alliance Commercial	$41.11

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC

Facility

$119,703.72

Service Code	MSDRG 268
Min. Negotiated Rate	$119,703.72
Max. Negotiated Rate	$119,703.72
Rate for Payer: Hawaii Medical Service Association Commercial	$119,703.72

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC

Facility

$103,309.79

Service Code	MSDRG 269
Min. Negotiated Rate	$103,309.79
Max. Negotiated Rate	$103,309.79
Rate for Payer: Hawaii Medical Service Association Commercial	$103,309.79

Aphasia Assessment Charge

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	8173988
Hospital Revenue Code	444
Min. Negotiated Rate	$59.90
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$59.90
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$430.78

Aphasia Assessment Charge

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	8173988
Hospital Revenue Code	444
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

Aphasia Assessment Charges ST

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	753733
Hospital Revenue Code	444
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

Aphasia Assessment Charges ST

Facility

$591.00

Service Code	HCPCS 96105 GO,CO
Hospital Charge Code	753733
Hospital Revenue Code	444
Min. Negotiated Rate	$59.90
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Western Management Group Commercial	$561.45
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$59.90
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$430.78

apixaban 2.5 mg tablet [HHSC]

Facility

$65.03

Service Code	NDC 00003089321
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$32.52
Max. Negotiated Rate	$63.08
Rate for Payer: AlohaCare Medicaid	$32.52
Rate for Payer: AlohaCare Medicare	$32.52
Rate for Payer: Cash Price	$42.27
Rate for Payer: Devoted Health Medicare	$35.77
Rate for Payer: Hawaii Medical Service Association Medicare	$32.52
Rate for Payer: Hawaii Western Management Group Commercial	$61.78
Rate for Payer: Health Management Network Commercial	$55.28
Rate for Payer: Humana Medicare	$32.52
Rate for Payer: Kaiser Permanente Commercial	$58.53
Rate for Payer: Kaiser Permanente Medicaid	$33.17
Rate for Payer: Kaiser Permanente Medicare	$32.52
Rate for Payer: MDX Hawaii PPO	$63.08
Rate for Payer: Ohana Health Plan Medicaid	$32.52
Rate for Payer: Ohana Health Plan Medicare	$32.52
Rate for Payer: UnitedHealthcare Medicaid	$39.02
Rate for Payer: UnitedHealthcare Medicare	$32.52
Rate for Payer: University Health Alliance Commercial	$47.40

apixaban 2.5 mg tablet [HHSC]

Facility

$65.03

Service Code	NDC 00003089321
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$55.28
Max. Negotiated Rate	$63.08
Rate for Payer: Cash Price	$42.27
Rate for Payer: Health Management Network Commercial	$55.28
Rate for Payer: Kaiser Permanente Commercial	$58.53
Rate for Payer: MDX Hawaii PPO	$63.08

apixaban 2.5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089331
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$42.92
Max. Negotiated Rate	$48.98
Rate for Payer: Cash Price	$32.83
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: MDX Hawaii PPO	$48.98

apixaban 2.5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089331
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$25.25
Max. Negotiated Rate	$48.98
Rate for Payer: AlohaCare Medicaid	$25.25
Rate for Payer: AlohaCare Medicare	$25.25
Rate for Payer: Cash Price	$32.83
Rate for Payer: Devoted Health Medicare	$27.77
Rate for Payer: Hawaii Medical Service Association Medicare	$25.25
Rate for Payer: Hawaii Western Management Group Commercial	$47.98
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Humana Medicare	$25.25
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: Kaiser Permanente Medicaid	$25.75
Rate for Payer: Kaiser Permanente Medicare	$25.25
Rate for Payer: MDX Hawaii PPO	$48.98
Rate for Payer: Ohana Health Plan Medicaid	$25.25
Rate for Payer: Ohana Health Plan Medicare	$25.25
Rate for Payer: UnitedHealthcare Medicaid	$30.30
Rate for Payer: UnitedHealthcare Medicare	$25.25
Rate for Payer: University Health Alliance Commercial	$36.81

apixaban 5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089431
Hospital Charge Code	2500065
Hospital Revenue Code	250
Min. Negotiated Rate	$42.92
Max. Negotiated Rate	$48.98
Rate for Payer: Cash Price	$32.83
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: MDX Hawaii PPO	$48.98

apixaban 5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089431
Hospital Charge Code	2500065
Hospital Revenue Code	250
Min. Negotiated Rate	$25.25
Max. Negotiated Rate	$48.98
Rate for Payer: AlohaCare Medicaid	$25.25
Rate for Payer: AlohaCare Medicare	$25.25
Rate for Payer: Cash Price	$32.83
Rate for Payer: Devoted Health Medicare	$27.77
Rate for Payer: Hawaii Medical Service Association Medicare	$25.25
Rate for Payer: Hawaii Western Management Group Commercial	$47.98
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Humana Medicare	$25.25
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: Kaiser Permanente Medicaid	$25.75
Rate for Payer: Kaiser Permanente Medicare	$25.25
Rate for Payer: MDX Hawaii PPO	$48.98
Rate for Payer: Ohana Health Plan Medicaid	$25.25
Rate for Payer: Ohana Health Plan Medicare	$25.25
Rate for Payer: UnitedHealthcare Medicaid	$30.30
Rate for Payer: UnitedHealthcare Medicare	$25.25
Rate for Payer: University Health Alliance Commercial	$36.81

APPENDIX PROCEDURES WITH CC

Facility

$34,088.15

Service Code	MSDRG 398
Min. Negotiated Rate	$34,088.15
Max. Negotiated Rate	$34,088.15
Rate for Payer: Hawaii Medical Service Association Commercial	$34,088.15

APPENDIX PROCEDURES WITH MCC

Facility

$36,918.21

Service Code	MSDRG 397
Min. Negotiated Rate	$36,918.21
Max. Negotiated Rate	$36,918.21
Rate for Payer: Hawaii Medical Service Association Commercial	$36,918.21

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$25,445.01

Service Code	MSDRG 399
Min. Negotiated Rate	$25,445.01
Max. Negotiated Rate	$25,445.01
Rate for Payer: Hawaii Medical Service Association Commercial	$25,445.01

AQUILEX FLUID CONTROL SYSTEM COMPLETE TUBE SET

Facility

$540.00

Hospital Charge Code	9390101
Hospital Revenue Code	272
Min. Negotiated Rate	$270.00
Max. Negotiated Rate	$523.80
Rate for Payer: AlohaCare Medicaid	$270.00
Rate for Payer: AlohaCare Medicare	$270.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$297.00
Rate for Payer: Hawaii Medical Service Association Medicare	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$513.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Humana Medicare	$270.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: Kaiser Permanente Medicaid	$275.40
Rate for Payer: Kaiser Permanente Medicare	$270.00
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: Ohana Health Plan Medicaid	$270.00
Rate for Payer: Ohana Health Plan Medicare	$270.00
Rate for Payer: UnitedHealthcare Medicare	$270.00
Rate for Payer: University Health Alliance Commercial	$393.61

AQUILEX FLUID CONTROL SYSTEM COMPLETE TUBE SET

Facility

$540.00

Hospital Charge Code	9390101
Hospital Revenue Code	272
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$523.80
Rate for Payer: Cash Price	$351.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: MDX Hawaii PPO	$523.80

Arterial Puncture (Blood Gas) Nursing

Facility

$255.00

Service Code	HCPCS 36600
Hospital Charge Code	11937722
Hospital Revenue Code	300
Min. Negotiated Rate	$216.75
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$165.75
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$247.35

Arterial Puncture (Blood Gas) Nursing

Facility

$255.00

Service Code	HCPCS 36600
Hospital Charge Code	11937722
Hospital Revenue Code	300
Min. Negotiated Rate	$15.16
Max. Negotiated Rate	$247.35
Rate for Payer: AlohaCare Medicaid	$127.50
Rate for Payer: AlohaCare Medicare	$127.50
Rate for Payer: Cash Price	$165.75
Rate for Payer: Cash Price	$165.75
Rate for Payer: Devoted Health Medicare	$140.25
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$127.50
Rate for Payer: Hawaii Western Management Group Commercial	$242.25
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Humana Medicare	$127.50
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$130.05
Rate for Payer: Kaiser Permanente Medicare	$127.50
Rate for Payer: MDX Hawaii PPO	$247.35
Rate for Payer: Ohana Health Plan Medicaid	$127.50
Rate for Payer: Ohana Health Plan Medicare	$127.50
Rate for Payer: UnitedHealthcare Medicaid	$15.16
Rate for Payer: UnitedHealthcare Medicare	$127.50
Rate for Payer: University Health Alliance Commercial	$185.87

ascorbic acid 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904052361
Hospital Charge Code	2500070
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

ascorbic acid 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904052361
Hospital Charge Code	2500070
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

ascorbic acid 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 79854030040
Hospital Charge Code	2500070
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

ascorbic acid 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 79854030040
Hospital Charge Code	2500070
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

aspirin 300 mg suppository [HHSC]

Facility

$8.11

Service Code	NDC 00574703412
Hospital Charge Code	2500071
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$7.87
Rate for Payer: AlohaCare Medicaid	$4.05
Rate for Payer: AlohaCare Medicare	$4.05
Rate for Payer: Cash Price	$5.27
Rate for Payer: Devoted Health Medicare	$4.46
Rate for Payer: Hawaii Medical Service Association Medicare	$4.05
Rate for Payer: Hawaii Western Management Group Commercial	$7.70
Rate for Payer: Health Management Network Commercial	$6.89
Rate for Payer: Humana Medicare	$4.05
Rate for Payer: Kaiser Permanente Commercial	$7.30
Rate for Payer: Kaiser Permanente Medicaid	$4.14
Rate for Payer: Kaiser Permanente Medicare	$4.05
Rate for Payer: MDX Hawaii PPO	$7.87
Rate for Payer: Ohana Health Plan Medicaid	$4.05
Rate for Payer: Ohana Health Plan Medicare	$4.05
Rate for Payer: UnitedHealthcare Medicaid	$4.87
Rate for Payer: UnitedHealthcare Medicare	$4.05
Rate for Payer: University Health Alliance Commercial	$5.91

Know your out-of-pocket cost for care.

All Charges