Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$32,175.95

Service Code	MSDRG 520
Min. Negotiated Rate	$32,175.95
Max. Negotiated Rate	$32,175.95
Rate for Payer: Hawaii Medical Service Association Commercial	$32,175.95

baclofen 10 mg tablet [HHSC]

Facility

$13.74

Service Code	NDC 70710128501
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$6.87
Max. Negotiated Rate	$13.33
Rate for Payer: AlohaCare Medicaid	$6.87
Rate for Payer: AlohaCare Medicare	$6.87
Rate for Payer: Cash Price	$8.93
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$6.87
Rate for Payer: Hawaii Western Management Group Commercial	$13.05
Rate for Payer: Health Management Network Commercial	$11.68
Rate for Payer: Humana Medicare	$6.87
Rate for Payer: Kaiser Permanente Commercial	$12.37
Rate for Payer: Kaiser Permanente Medicaid	$7.01
Rate for Payer: Kaiser Permanente Medicare	$6.87
Rate for Payer: MDX Hawaii PPO	$13.33
Rate for Payer: Ohana Health Plan Medicaid	$6.87
Rate for Payer: Ohana Health Plan Medicare	$6.87
Rate for Payer: UnitedHealthcare Medicaid	$8.24
Rate for Payer: UnitedHealthcare Medicare	$6.87
Rate for Payer: University Health Alliance Commercial	$10.02

baclofen 10 mg tablet [HHSC]

Facility

$4.10

Service Code	NDC 60687050301
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$3.98
Rate for Payer: Cash Price	$2.66
Rate for Payer: Health Management Network Commercial	$3.48
Rate for Payer: Kaiser Permanente Commercial	$3.69
Rate for Payer: MDX Hawaii PPO	$3.98

baclofen 10 mg tablet [HHSC]

Facility

$3.46

Service Code	NDC 50268010615
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.36
Rate for Payer: AlohaCare Medicaid	$1.73
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$2.25
Rate for Payer: Devoted Health Medicare	$1.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.29
Rate for Payer: Health Management Network Commercial	$2.94
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$3.11
Rate for Payer: Kaiser Permanente Medicaid	$1.76
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$3.36
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$2.08
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$2.52

baclofen 10 mg tablet [HHSC]

Facility

$4.10

Service Code	NDC 60687050301
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$3.98
Rate for Payer: AlohaCare Medicaid	$2.05
Rate for Payer: AlohaCare Medicare	$2.05
Rate for Payer: Cash Price	$2.66
Rate for Payer: Devoted Health Medicare	$2.25
Rate for Payer: Hawaii Medical Service Association Medicare	$2.05
Rate for Payer: Hawaii Western Management Group Commercial	$3.90
Rate for Payer: Health Management Network Commercial	$3.48
Rate for Payer: Humana Medicare	$2.05
Rate for Payer: Kaiser Permanente Commercial	$3.69
Rate for Payer: Kaiser Permanente Medicaid	$2.09
Rate for Payer: Kaiser Permanente Medicare	$2.05
Rate for Payer: MDX Hawaii PPO	$3.98
Rate for Payer: Ohana Health Plan Medicaid	$2.05
Rate for Payer: Ohana Health Plan Medicare	$2.05
Rate for Payer: UnitedHealthcare Medicaid	$2.46
Rate for Payer: UnitedHealthcare Medicare	$2.05
Rate for Payer: University Health Alliance Commercial	$2.99

baclofen 10 mg tablet [HHSC]

Facility

$3.46

Service Code	NDC 50268010615
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Management Network Commercial	$2.94
Rate for Payer: Kaiser Permanente Commercial	$3.11
Rate for Payer: MDX Hawaii PPO	$3.36

baclofen 10 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904647561
Hospital Charge Code	2500100
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

baclofen 10 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904647561
Hospital Charge Code	2500100
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

baclofen 10 mg tablet [HHSC]

Facility

$4.10

Service Code	NDC 68084085501
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$3.98
Rate for Payer: AlohaCare Medicaid	$2.05
Rate for Payer: AlohaCare Medicare	$2.05
Rate for Payer: Cash Price	$2.66
Rate for Payer: Devoted Health Medicare	$2.25
Rate for Payer: Hawaii Medical Service Association Medicare	$2.05
Rate for Payer: Hawaii Western Management Group Commercial	$3.90
Rate for Payer: Health Management Network Commercial	$3.48
Rate for Payer: Humana Medicare	$2.05
Rate for Payer: Kaiser Permanente Commercial	$3.69
Rate for Payer: Kaiser Permanente Medicaid	$2.09
Rate for Payer: Kaiser Permanente Medicare	$2.05
Rate for Payer: MDX Hawaii PPO	$3.98
Rate for Payer: Ohana Health Plan Medicaid	$2.05
Rate for Payer: Ohana Health Plan Medicare	$2.05
Rate for Payer: UnitedHealthcare Medicaid	$2.46
Rate for Payer: UnitedHealthcare Medicare	$2.05
Rate for Payer: University Health Alliance Commercial	$2.99

baclofen 10 mg tablet [HHSC]

Facility

$4.10

Service Code	NDC 68084085501
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$3.98
Rate for Payer: Cash Price	$2.66
Rate for Payer: Health Management Network Commercial	$3.48
Rate for Payer: Kaiser Permanente Commercial	$3.69
Rate for Payer: MDX Hawaii PPO	$3.98

baclofen 10 mg tablet [HHSC]

Facility

$3.46

Service Code	NDC 60687081501
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Management Network Commercial	$2.94
Rate for Payer: Kaiser Permanente Commercial	$3.11
Rate for Payer: MDX Hawaii PPO	$3.36

baclofen 10 mg tablet [HHSC]

Facility

$13.74

Service Code	NDC 70710128501
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$13.33
Rate for Payer: Cash Price	$8.93
Rate for Payer: Health Management Network Commercial	$11.68
Rate for Payer: Kaiser Permanente Commercial	$12.37
Rate for Payer: MDX Hawaii PPO	$13.33

baclofen 10 mg tablet [HHSC]

Facility

$3.46

Service Code	NDC 60687081501
Hospital Charge Code	2500100
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.36
Rate for Payer: AlohaCare Medicaid	$1.73
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$2.25
Rate for Payer: Devoted Health Medicare	$1.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.29
Rate for Payer: Health Management Network Commercial	$2.94
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$3.11
Rate for Payer: Kaiser Permanente Medicaid	$1.76
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$3.36
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$2.08
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$2.52

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$55,198.84

Service Code	MSDRG 095
Min. Negotiated Rate	$55,198.84
Max. Negotiated Rate	$55,198.84
Rate for Payer: Hawaii Medical Service Association Commercial	$55,198.84

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$55,198.84

Service Code	MSDRG 094
Min. Negotiated Rate	$55,198.84
Max. Negotiated Rate	$55,198.84
Rate for Payer: Hawaii Medical Service Association Commercial	$55,198.84

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$55,198.84

Service Code	MSDRG 096
Min. Negotiated Rate	$55,198.84
Max. Negotiated Rate	$55,198.84
Rate for Payer: Hawaii Medical Service Association Commercial	$55,198.84

BAKRI BALLOON

Facility

$1,384.00

Service Code	HCPCS C1725
Hospital Charge Code	9271650
Hospital Revenue Code	272
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

BAKRI BALLOON

Facility

$1,384.00

Service Code	HCPCS C1725
Hospital Charge Code	9271650
Hospital Revenue Code	272
Min. Negotiated Rate	$692.00
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,314.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$1,008.80

BANDAGE TENSOPLAST 2X5YD SUPPORT /COMPRESSION ELST TAN LTX 1/RL, 36 RL/CA

Facility

$2.00

Hospital Charge Code	12954858
Hospital Revenue Code	272
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

BANDAGE TENSOPLAST 2X5YD SUPPORT /COMPRESSION ELST TAN LTX 1/RL, 36 RL/CA

Facility

$2.00

Hospital Charge Code	12954858
Hospital Revenue Code	272
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$1.00
Rate for Payer: Cash Price	$1.30
Rate for Payer: Devoted Health Medicare	$1.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1.00
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$1.00
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$1.00
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$1.00
Rate for Payer: Ohana Health Plan Medicare	$1.00
Rate for Payer: UnitedHealthcare Medicare	$1.00
Rate for Payer: University Health Alliance Commercial	$1.46

.Barbiturates, Ur Cnfrm FSI

Facility

$174.00

Service Code	HCPCS 80345
Hospital Charge Code	8728196
Hospital Revenue Code	301
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$168.78
Rate for Payer: AlohaCare Medicaid	$87.00
Rate for Payer: AlohaCare Medicare	$87.00
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Devoted Health Medicare	$95.70
Rate for Payer: Hawaii Medical Service Association ABD	$15.80
Rate for Payer: Hawaii Medical Service Association Medicare	$87.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.59
Rate for Payer: Hawaii Western Management Group Commercial	$165.30
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Humana Medicare	$87.00
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: Kaiser Permanente Medicare	$87.00
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: Ohana Health Plan Medicaid	$87.00
Rate for Payer: Ohana Health Plan Medicare	$87.00
Rate for Payer: UnitedHealthcare Medicare	$87.00
Rate for Payer: University Health Alliance Commercial	$126.83

.Barbiturates, Ur Cnfrm FSI

Facility

$174.00

Service Code	HCPCS 80345
Hospital Charge Code	8728196
Hospital Revenue Code	301
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: MDX Hawaii PPO	$168.78

Barbiturates, Urine Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8228839
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Barbiturates, Urine Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8228839
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

Basic Metabolic Panel (BMP) FSI

Facility

$117.00

Service Code	HCPCS 80048
Hospital Charge Code	8117854
Hospital Revenue Code	301
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$113.49
Rate for Payer: Cash Price	$76.05
Rate for Payer: Health Management Network Commercial	$99.45
Rate for Payer: Kaiser Permanente Commercial	$105.30
Rate for Payer: MDX Hawaii PPO	$113.49

Know your out-of-pocket cost for care.

All Charges