Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

aspirin EC 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084084825
Hospital Charge Code	2500072
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

aspirin EC 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904671260
Hospital Charge Code	2500072
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

aspirin EC 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904671260
Hospital Charge Code	2500072
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 EC 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00603016921
Hospital Charge Code	2500072
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 EC 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 69618001501
Hospital Charge Code	2500072
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 EC 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084084825
Hospital Charge Code	2500072
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 EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399862702
Hospital Charge Code	2500075
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

aspirin EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399101402
Hospital Charge Code	2500075
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 EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 46122018076
Hospital Charge Code	2500075
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

aspirin EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399101402
Hospital Charge Code	2500075
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

aspirin EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536123441
Hospital Charge Code	2500075
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

aspirin EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 63739052210
Hospital Charge Code	2500075
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 EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 46122018076
Hospital Charge Code	2500075
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 EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399862702
Hospital Charge Code	2500075
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 EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536123441
Hospital Charge Code	2500075
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 EC 81 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 63739052210
Hospital Charge Code	2500075
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

Assist with procedure - Chest Tube Activity:

Facility

$3,290.00

Service Code	HCPCS 32551
Hospital Charge Code	4255022
Hospital Revenue Code	761
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,191.30
Rate for Payer: AlohaCare Medicaid	$1,645.00
Rate for Payer: AlohaCare Medicare	$1,645.00
Rate for Payer: Cash Price	$2,138.50
Rate for Payer: Cash Price	$2,138.50
Rate for Payer: Devoted Health Medicare	$1,809.50
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,645.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,125.50
Rate for Payer: Health Management Network Commercial	$2,796.50
Rate for Payer: Humana Medicare	$1,645.00
Rate for Payer: Kaiser Permanente Commercial	$2,961.00
Rate for Payer: Kaiser Permanente Medicaid	$1,677.90
Rate for Payer: Kaiser Permanente Medicare	$1,645.00
Rate for Payer: MDX Hawaii PPO	$3,191.30
Rate for Payer: Ohana Health Plan Medicaid	$1,645.00
Rate for Payer: Ohana Health Plan Medicare	$1,645.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,645.00
Rate for Payer: University Health Alliance Commercial	$2,398.08

Assist with procedure - Chest Tube Activity:

Facility

$3,290.00

Service Code	HCPCS 32551
Hospital Charge Code	4255022
Hospital Revenue Code	761
Min. Negotiated Rate	$2,796.50
Max. Negotiated Rate	$3,191.30
Rate for Payer: Cash Price	$2,138.50
Rate for Payer: Health Management Network Commercial	$2,796.50
Rate for Payer: Kaiser Permanente Commercial	$2,961.00
Rate for Payer: MDX Hawaii PPO	$3,191.30

AST (SGOT) FSI

Facility

$92.00

Service Code	HCPCS 84450
Hospital Charge Code	8117852
Hospital Revenue Code	301
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$89.24
Rate for Payer: AlohaCare Medicaid	$46.00
Rate for Payer: AlohaCare Medicare	$46.00
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$50.60
Rate for Payer: Hawaii Medical Service Association ABD	$7.14
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$46.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Humana Medicare	$46.00
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: Kaiser Permanente Medicaid	$46.92
Rate for Payer: Kaiser Permanente Medicare	$46.00
Rate for Payer: MDX Hawaii PPO	$89.24
Rate for Payer: Ohana Health Plan Medicaid	$46.00
Rate for Payer: Ohana Health Plan Medicare	$46.00
Rate for Payer: UnitedHealthcare Medicaid	$7.14
Rate for Payer: UnitedHealthcare Medicare	$46.00
Rate for Payer: University Health Alliance Commercial	$13.36

AST (SGOT) FSI

Facility

$92.00

Service Code	HCPCS 84450
Hospital Charge Code	8117852
Hospital Revenue Code	301
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

atenolol 25 mg tablet [HHSC]

Facility

$4.45

Service Code	NDC 51079075920
Hospital Charge Code	2500076
Hospital Revenue Code	250
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$4.32
Rate for Payer: Cash Price	$2.89
Rate for Payer: Health Management Network Commercial	$3.78
Rate for Payer: Kaiser Permanente Commercial	$4.00
Rate for Payer: MDX Hawaii PPO	$4.32

atenolol 25 mg tablet [HHSC]

Facility

$4.45

Service Code	NDC 51079075920
Hospital Charge Code	2500076
Hospital Revenue Code	250
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$4.32
Rate for Payer: AlohaCare Medicaid	$2.23
Rate for Payer: AlohaCare Medicare	$2.23
Rate for Payer: Cash Price	$2.89
Rate for Payer: Devoted Health Medicare	$2.45
Rate for Payer: Hawaii Medical Service Association Medicare	$2.23
Rate for Payer: Hawaii Western Management Group Commercial	$4.23
Rate for Payer: Health Management Network Commercial	$3.78
Rate for Payer: Humana Medicare	$2.23
Rate for Payer: Kaiser Permanente Commercial	$4.00
Rate for Payer: Kaiser Permanente Medicaid	$2.27
Rate for Payer: Kaiser Permanente Medicare	$2.23
Rate for Payer: MDX Hawaii PPO	$4.32
Rate for Payer: Ohana Health Plan Medicaid	$2.23
Rate for Payer: Ohana Health Plan Medicare	$2.23
Rate for Payer: UnitedHealthcare Medicaid	$2.67
Rate for Payer: UnitedHealthcare Medicare	$2.23
Rate for Payer: University Health Alliance Commercial	$3.24

atenolol 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687060501
Hospital Charge Code	2500076
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

atenolol 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687060501
Hospital Charge Code	2500076
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

atenolol 50 mg tablet [HHSC]

Facility

$4.96

Service Code	NDC 51079068420
Hospital Charge Code	2500077
Hospital Revenue Code	250
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$4.81
Rate for Payer: Cash Price	$3.22
Rate for Payer: Health Management Network Commercial	$4.22
Rate for Payer: Kaiser Permanente Commercial	$4.46
Rate for Payer: MDX Hawaii PPO	$4.81

Know your out-of-pocket cost for care.

All Charges