Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

calcium-vit D 600mg-400 unit tablet [HHSC]

Facility

$3.00

Service Code	NDC 80681013900
Hospital Charge Code	2500138
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

calcium-vit D 600mg-400 unit tablet [HHSC]

Facility

$3.72

Service Code	NDC 50268015015
Hospital Charge Code	2500138
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$3.61
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Management Network Commercial	$3.16
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: MDX Hawaii PPO	$3.61

calcium-vit D 600mg-400 unit tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904323352
Hospital Charge Code	2500138
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

calcium-vit D 600mg-400 unit tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904323306
Hospital Charge Code	2500138
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

calcium-vit D 600mg-400 unit tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904323306
Hospital Charge Code	2500138
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

calfactant intratrach 210mg/6 mL vial [HHSC]

Facility

$1,925.14

Service Code	NDC 61938045606
Hospital Charge Code	2500139
Hospital Revenue Code	250
Min. Negotiated Rate	$962.57
Max. Negotiated Rate	$1,867.39
Rate for Payer: AlohaCare Medicaid	$962.57
Rate for Payer: AlohaCare Medicare	$962.57
Rate for Payer: Cash Price	$1,251.34
Rate for Payer: Devoted Health Medicare	$1,058.83
Rate for Payer: Hawaii Medical Service Association Medicare	$962.57
Rate for Payer: Hawaii Western Management Group Commercial	$1,828.88
Rate for Payer: Health Management Network Commercial	$1,636.37
Rate for Payer: Humana Medicare	$962.57
Rate for Payer: Kaiser Permanente Commercial	$1,732.63
Rate for Payer: Kaiser Permanente Medicaid	$981.82
Rate for Payer: Kaiser Permanente Medicare	$962.57
Rate for Payer: MDX Hawaii PPO	$1,867.39
Rate for Payer: Ohana Health Plan Medicaid	$962.57
Rate for Payer: Ohana Health Plan Medicare	$962.57
Rate for Payer: UnitedHealthcare Medicaid	$1,155.08
Rate for Payer: UnitedHealthcare Medicare	$962.57
Rate for Payer: University Health Alliance Commercial	$1,403.23

calfactant intratrach 210mg/6 mL vial [HHSC]

Facility

$1,925.14

Service Code	NDC 61938045606
Hospital Charge Code	2500139
Hospital Revenue Code	250
Min. Negotiated Rate	$1,636.37
Max. Negotiated Rate	$1,867.39
Rate for Payer: Cash Price	$1,251.34
Rate for Payer: Health Management Network Commercial	$1,636.37
Rate for Payer: Kaiser Permanente Commercial	$1,732.63
Rate for Payer: MDX Hawaii PPO	$1,867.39

CALIBRATED DRILL, 4.0MM X 280MM

Facility

$388.00

Hospital Charge Code	12970969
Hospital Revenue Code	272
Min. Negotiated Rate	$194.00
Max. Negotiated Rate	$376.36
Rate for Payer: AlohaCare Medicaid	$194.00
Rate for Payer: AlohaCare Medicare	$194.00
Rate for Payer: Cash Price	$252.20
Rate for Payer: Devoted Health Medicare	$213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$194.00
Rate for Payer: Hawaii Western Management Group Commercial	$368.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Humana Medicare	$194.00
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: Kaiser Permanente Medicare	$194.00
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: Ohana Health Plan Medicaid	$194.00
Rate for Payer: Ohana Health Plan Medicare	$194.00
Rate for Payer: UnitedHealthcare Medicare	$194.00
Rate for Payer: University Health Alliance Commercial	$282.81

CALIBRATED DRILL, 4.0MM X 280MM

Facility

$388.00

Hospital Charge Code	12970969
Hospital Revenue Code	272
Min. Negotiated Rate	$329.80
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: MDX Hawaii PPO	$376.36

CALIBRATED DRILL, A-O STYLE, 5.5MM

Facility

$690.00

Hospital Charge Code	12970970
Hospital Revenue Code	272
Min. Negotiated Rate	$345.00
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$345.00
Rate for Payer: Cash Price	$448.50
Rate for Payer: Devoted Health Medicare	$379.50
Rate for Payer: Hawaii Medical Service Association Medicare	$345.00
Rate for Payer: Hawaii Western Management Group Commercial	$655.50
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$345.00
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$345.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$345.00
Rate for Payer: Ohana Health Plan Medicare	$345.00
Rate for Payer: UnitedHealthcare Medicare	$345.00
Rate for Payer: University Health Alliance Commercial	$502.94

CALIBRATED DRILL, A-O STYLE, 5.5MM

Facility

$690.00

Hospital Charge Code	12970970
Hospital Revenue Code	272
Min. Negotiated Rate	$586.50
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$448.50
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30

CALIBRATED STEP DRILL, 4.8/6.0MM

Facility

$910.00

Hospital Charge Code	12970972
Hospital Revenue Code	272
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$882.70
Rate for Payer: AlohaCare Medicaid	$455.00
Rate for Payer: AlohaCare Medicare	$455.00
Rate for Payer: Cash Price	$591.50
Rate for Payer: Devoted Health Medicare	$500.50
Rate for Payer: Hawaii Medical Service Association Medicare	$455.00
Rate for Payer: Hawaii Western Management Group Commercial	$864.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Humana Medicare	$455.00
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: Kaiser Permanente Medicare	$455.00
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: Ohana Health Plan Medicaid	$455.00
Rate for Payer: Ohana Health Plan Medicare	$455.00
Rate for Payer: UnitedHealthcare Medicare	$455.00
Rate for Payer: University Health Alliance Commercial	$663.30

CALIBRATED STEP DRILL, 4.8/6.0MM

Facility

$910.00

Hospital Charge Code	12970972
Hospital Revenue Code	272
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$591.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Kaiser Permanente Commercial	$819.00
Rate for Payer: MDX Hawaii PPO	$882.70

CALIBRATED STEP DRILL, A-O STYLE, 5.0MM

Facility

$779.00

Hospital Charge Code	12970974
Hospital Revenue Code	272
Min. Negotiated Rate	$389.50
Max. Negotiated Rate	$755.63
Rate for Payer: AlohaCare Medicaid	$389.50
Rate for Payer: AlohaCare Medicare	$389.50
Rate for Payer: Cash Price	$506.35
Rate for Payer: Devoted Health Medicare	$428.45
Rate for Payer: Hawaii Medical Service Association Medicare	$389.50
Rate for Payer: Hawaii Western Management Group Commercial	$740.05
Rate for Payer: Health Management Network Commercial	$662.15
Rate for Payer: Humana Medicare	$389.50
Rate for Payer: Kaiser Permanente Commercial	$701.10
Rate for Payer: Kaiser Permanente Medicaid	$397.29
Rate for Payer: Kaiser Permanente Medicare	$389.50
Rate for Payer: MDX Hawaii PPO	$755.63
Rate for Payer: Ohana Health Plan Medicaid	$389.50
Rate for Payer: Ohana Health Plan Medicare	$389.50
Rate for Payer: UnitedHealthcare Medicare	$389.50
Rate for Payer: University Health Alliance Commercial	$567.81

CALIBRATED STEP DRILL, A-O STYLE, 5.0MM

Facility

$779.00

Hospital Charge Code	12970974
Hospital Revenue Code	272
Min. Negotiated Rate	$662.15
Max. Negotiated Rate	$755.63
Rate for Payer: Cash Price	$506.35
Rate for Payer: Health Management Network Commercial	$662.15
Rate for Payer: Kaiser Permanente Commercial	$701.10
Rate for Payer: MDX Hawaii PPO	$755.63

.CALR Exon 9 Rfx MPL FSI

Facility

$523.00

Service Code	HCPCS 81219
Hospital Charge Code	10596934
Hospital Revenue Code	310
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$339.95
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: MDX Hawaii PPO	$507.31

.CALR Exon 9 Rfx MPL FSI

Facility

$523.00

Service Code	HCPCS 81219
Hospital Charge Code	10596934
Hospital Revenue Code	310
Min. Negotiated Rate	$99.41
Max. Negotiated Rate	$507.31
Rate for Payer: AlohaCare Medicaid	$261.50
Rate for Payer: AlohaCare Medicare	$261.50
Rate for Payer: Cash Price	$339.95
Rate for Payer: Cash Price	$339.95
Rate for Payer: Devoted Health Medicare	$287.65
Rate for Payer: Hawaii Medical Service Association ABD	$122.60
Rate for Payer: Hawaii Medical Service Association Commercial	$152.04
Rate for Payer: Hawaii Medical Service Association Medicare	$261.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.60
Rate for Payer: Hawaii Western Management Group Commercial	$121.63
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Humana Medicare	$261.50
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: Kaiser Permanente Medicaid	$266.73
Rate for Payer: Kaiser Permanente Medicare	$261.50
Rate for Payer: MDX Hawaii PPO	$507.31
Rate for Payer: Ohana Health Plan Medicaid	$261.50
Rate for Payer: Ohana Health Plan Medicare	$261.50
Rate for Payer: UnitedHealthcare Medicaid	$99.41
Rate for Payer: UnitedHealthcare Medicare	$261.50
Rate for Payer: University Health Alliance Commercial	$381.21

Campylobacter Antigen Bill Only

Facility

$70.00

Service Code	HCPCS 87449
Hospital Charge Code	13145598
Hospital Revenue Code	306
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: MDX Hawaii PPO	$67.90

Campylobacter Antigen Bill Only

Facility

$70.00

Service Code	HCPCS 87449
Hospital Charge Code	13145598
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$67.90
Rate for Payer: AlohaCare Medicaid	$35.00
Rate for Payer: AlohaCare Medicare	$35.00
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Devoted Health Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$14.97
Rate for Payer: Hawaii Medical Service Association Medicare	$35.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$11.98
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Humana Medicare	$35.00
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: Kaiser Permanente Medicare	$35.00
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: Ohana Health Plan Medicaid	$35.00
Rate for Payer: Ohana Health Plan Medicare	$35.00
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$35.00
Rate for Payer: University Health Alliance Commercial	$31.01

CANCELLOUS SCREW, CAPTURED, FT,6.5X100MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	12970991
Hospital Revenue Code	278
Min. Negotiated Rate	$345.00
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$345.00
Rate for Payer: Cash Price	$448.50
Rate for Payer: Devoted Health Medicare	$379.50
Rate for Payer: Hawaii Medical Service Association Medicare	$345.00
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$345.00
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$345.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$345.00
Rate for Payer: Ohana Health Plan Medicare	$345.00
Rate for Payer: UnitedHealthcare Medicare	$345.00
Rate for Payer: University Health Alliance Commercial	$386.40

CANCELLOUS SCREW, CAPTURED, FT,6.5X100MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	12970991
Hospital Revenue Code	278
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$448.50
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: University Health Alliance Commercial	$386.40

CANCELLOUS SCREW, CAPTURED, FT,6.5X105MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	12970995
Hospital Revenue Code	278
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$448.50
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: University Health Alliance Commercial	$386.40

CANCELLOUS SCREW, CAPTURED, FT,6.5X105MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	12970995
Hospital Revenue Code	278
Min. Negotiated Rate	$345.00
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$345.00
Rate for Payer: Cash Price	$448.50
Rate for Payer: Devoted Health Medicare	$379.50
Rate for Payer: Hawaii Medical Service Association Medicare	$345.00
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$345.00
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$345.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$345.00
Rate for Payer: Ohana Health Plan Medicare	$345.00
Rate for Payer: UnitedHealthcare Medicare	$345.00
Rate for Payer: University Health Alliance Commercial	$386.40

CANCELLOUS SCREW, CAPTURED, FT,6.5X110MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	12970996
Hospital Revenue Code	278
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$669.30
Rate for Payer: Cash Price	$448.50
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: University Health Alliance Commercial	$386.40

CANCELLOUS SCREW, CAPTURED, FT,6.5X110MM

Facility

$690.00

Service Code	HCPCS C1713
Hospital Charge Code	12970996
Hospital Revenue Code	278
Min. Negotiated Rate	$345.00
Max. Negotiated Rate	$669.30
Rate for Payer: AlohaCare Medicaid	$345.00
Rate for Payer: AlohaCare Medicare	$345.00
Rate for Payer: Cash Price	$448.50
Rate for Payer: Devoted Health Medicare	$379.50
Rate for Payer: Hawaii Medical Service Association Medicare	$345.00
Rate for Payer: Hawaii Western Management Group Commercial	$483.00
Rate for Payer: Health Management Network Commercial	$586.50
Rate for Payer: Humana Medicare	$345.00
Rate for Payer: Kaiser Permanente Commercial	$621.00
Rate for Payer: Kaiser Permanente Medicaid	$351.90
Rate for Payer: Kaiser Permanente Medicare	$345.00
Rate for Payer: MDX Hawaii PPO	$669.30
Rate for Payer: Ohana Health Plan Medicaid	$345.00
Rate for Payer: Ohana Health Plan Medicare	$345.00
Rate for Payer: UnitedHealthcare Medicare	$345.00
Rate for Payer: University Health Alliance Commercial	$386.40

Know your out-of-pocket cost for care.

All Charges