Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

CAROTID ARTERY STENT PROCEDURES WITH MCC

Facility

$10,400.00

Service Code	MSDRG 034
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$10,400.00
Rate for Payer: University Health Alliance Commercial	$10,400.00

CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC

Facility

$10,400.00

Service Code	MSDRG 036
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$10,400.00
Rate for Payer: University Health Alliance Commercial	$10,400.00

CARRIER SKIN GRAFT DERMA CARRIER II 3:1

Facility

$202.00

Hospital Charge Code	8348093
Hospital Revenue Code	270
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$131.30
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: MDX Hawaii PPO	$195.94

CARRIER SKIN GRAFT DERMA CARRIER II 3:1

Facility

$202.00

Hospital Charge Code	8348093
Hospital Revenue Code	270
Min. Negotiated Rate	$101.00
Max. Negotiated Rate	$195.94
Rate for Payer: AlohaCare Medicaid	$101.00
Rate for Payer: AlohaCare Medicare	$101.00
Rate for Payer: Cash Price	$131.30
Rate for Payer: Devoted Health Medicare	$111.10
Rate for Payer: Hawaii Medical Service Association Medicare	$101.00
Rate for Payer: Hawaii Western Management Group Commercial	$191.90
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Humana Medicare	$101.00
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: Kaiser Permanente Medicare	$101.00
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: Ohana Health Plan Medicaid	$101.00
Rate for Payer: Ohana Health Plan Medicare	$101.00
Rate for Payer: UnitedHealthcare Medicare	$101.00
Rate for Payer: University Health Alliance Commercial	$147.24

CAR SEAT/ BED TESTING 1ST HOUR CHARGE

Professional

Both

$52.00

Service Code	HCPCS 94780
Hospital Charge Code	8243417
Hospital Revenue Code	960
Min. Negotiated Rate	$20.41
Max. Negotiated Rate	$44.20
Rate for Payer: AlohaCare Medicaid	$23.42
Rate for Payer: AlohaCare Medicare	$20.41
Rate for Payer: Cash Price	$33.80
Rate for Payer: Cash Price	$33.80
Rate for Payer: Devoted Health Medicare	$22.45
Rate for Payer: Hawaii Medical Service Association ABD	$23.42
Rate for Payer: Hawaii Medical Service Association Medicare	$20.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.42
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Kaiser Permanente Commercial	$22.45
Rate for Payer: Kaiser Permanente Medicaid	$22.45
Rate for Payer: Kaiser Permanente Medicare	$22.45
Rate for Payer: Ohana Health Plan Medicaid	$23.42
Rate for Payer: Ohana Health Plan Medicare	$20.41
Rate for Payer: UnitedHealthcare Medicaid	$23.42
Rate for Payer: UnitedHealthcare Medicare	$20.41
Rate for Payer: University Health Alliance Commercial	$28.80

CAR SEAT/ BED TESTING 1ST HOUR CHARGE

Facility

$195.00

Service Code	HCPCS 94780
Hospital Charge Code	8243417
Hospital Revenue Code	410
Min. Negotiated Rate	$14.47
Max. Negotiated Rate	$189.15
Rate for Payer: AlohaCare Medicaid	$97.50
Rate for Payer: AlohaCare Medicare	$97.50
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Devoted Health Medicare	$107.25
Rate for Payer: Hawaii Medical Service Association Commercial	$47.70
Rate for Payer: Hawaii Medical Service Association Medicare	$97.50
Rate for Payer: Hawaii Western Management Group Commercial	$185.25
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Humana Medicare	$97.50
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: Kaiser Permanente Medicare	$97.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: Ohana Health Plan Medicaid	$97.50
Rate for Payer: Ohana Health Plan Medicare	$97.50
Rate for Payer: UnitedHealthcare Medicaid	$14.47
Rate for Payer: UnitedHealthcare Medicare	$97.50
Rate for Payer: University Health Alliance Commercial	$142.14

CAR SEAT/ BED TESTING 1ST HOUR CHARGE

Facility

$195.00

Service Code	HCPCS 94780
Hospital Charge Code	8243417
Hospital Revenue Code	410
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$126.75
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: MDX Hawaii PPO	$189.15

CAR SEAT/ BED TESTING ADDL 30 MIN CHARGE

Facility

$55.00

Service Code	HCPCS 94781
Hospital Charge Code	8243381
Hospital Revenue Code	410
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

CAR SEAT/ BED TESTING ADDL 30 MIN CHARGE

Facility

$55.00

Service Code	HCPCS 94781
Hospital Charge Code	8243381
Hospital Revenue Code	410
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicaid	$5.03
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$40.09

CAR SEAT/ BED TESTING ADDL 30 MIN CHARGE

Professional

Both

$29.00

Service Code	HCPCS 94781
Hospital Charge Code	8243381
Hospital Revenue Code	960
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$24.65
Rate for Payer: AlohaCare Medicaid	$8.14
Rate for Payer: AlohaCare Medicare	$7.01
Rate for Payer: Cash Price	$18.85
Rate for Payer: Cash Price	$18.85
Rate for Payer: Devoted Health Medicare	$7.71
Rate for Payer: Hawaii Medical Service Association ABD	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.14
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$7.71
Rate for Payer: Kaiser Permanente Medicaid	$7.71
Rate for Payer: Kaiser Permanente Medicare	$7.71
Rate for Payer: Ohana Health Plan Medicaid	$8.14
Rate for Payer: Ohana Health Plan Medicare	$7.01
Rate for Payer: UnitedHealthcare Medicaid	$8.14
Rate for Payer: UnitedHealthcare Medicare	$7.01
Rate for Payer: University Health Alliance Commercial	$9.92

Car Seat Oximetry Challenge Follow Up

Professional

Both

$46.00

Service Code	HCPCS 94781
Hospital Charge Code	7548540
Hospital Revenue Code	410
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$39.10
Rate for Payer: AlohaCare Medicaid	$8.14
Rate for Payer: AlohaCare Medicare	$7.01
Rate for Payer: Cash Price	$29.90
Rate for Payer: Cash Price	$29.90
Rate for Payer: Devoted Health Medicare	$7.71
Rate for Payer: Hawaii Medical Service Association ABD	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.14
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$7.71
Rate for Payer: Kaiser Permanente Medicaid	$7.71
Rate for Payer: Kaiser Permanente Medicare	$7.71
Rate for Payer: Ohana Health Plan Medicaid	$8.14
Rate for Payer: Ohana Health Plan Medicare	$7.01
Rate for Payer: UnitedHealthcare Medicaid	$8.14
Rate for Payer: UnitedHealthcare Medicare	$7.01
Rate for Payer: University Health Alliance Commercial	$9.92

Car Seat Oximetry Challenge Follow Up

Facility

$125.00

Service Code	HCPCS 94781
Hospital Charge Code	7548540
Hospital Revenue Code	410
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$62.50
Rate for Payer: AlohaCare Medicare	$62.50
Rate for Payer: Cash Price	$81.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Devoted Health Medicare	$68.75
Rate for Payer: Hawaii Medical Service Association Medicare	$62.50
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Humana Medicare	$62.50
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$62.50
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: Ohana Health Plan Medicaid	$62.50
Rate for Payer: Ohana Health Plan Medicare	$62.50
Rate for Payer: UnitedHealthcare Medicaid	$5.03
Rate for Payer: UnitedHealthcare Medicare	$62.50
Rate for Payer: University Health Alliance Commercial	$91.11

Car Seat Oximetry Challenge Follow Up

Facility

$125.00

Service Code	HCPCS 94781
Hospital Charge Code	7548540
Hospital Revenue Code	410
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: MDX Hawaii PPO	$121.25

Car Seat Oximetry Challenge Initial

Professional

Both

$138.00

Service Code	HCPCS 94780
Hospital Charge Code	1666889
Hospital Revenue Code	410
Min. Negotiated Rate	$20.41
Max. Negotiated Rate	$117.30
Rate for Payer: AlohaCare Medicaid	$23.42
Rate for Payer: AlohaCare Medicare	$20.41
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$22.45
Rate for Payer: Hawaii Medical Service Association ABD	$23.42
Rate for Payer: Hawaii Medical Service Association Medicare	$20.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.42
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$22.45
Rate for Payer: Kaiser Permanente Medicaid	$22.45
Rate for Payer: Kaiser Permanente Medicare	$22.45
Rate for Payer: Ohana Health Plan Medicaid	$23.42
Rate for Payer: Ohana Health Plan Medicare	$20.41
Rate for Payer: UnitedHealthcare Medicaid	$23.42
Rate for Payer: UnitedHealthcare Medicare	$20.41
Rate for Payer: University Health Alliance Commercial	$28.80

Car Seat Oximetry Challenge Initial

Facility

$216.00

Service Code	HCPCS 94780
Hospital Charge Code	1666889
Hospital Revenue Code	410
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$209.52
Rate for Payer: Cash Price	$140.40
Rate for Payer: Health Management Network Commercial	$183.60
Rate for Payer: Kaiser Permanente Commercial	$194.40
Rate for Payer: MDX Hawaii PPO	$209.52

Car Seat Oximetry Challenge Initial

Facility

$216.00

Service Code	HCPCS 94780
Hospital Charge Code	1666889
Hospital Revenue Code	410
Min. Negotiated Rate	$14.47
Max. Negotiated Rate	$209.52
Rate for Payer: AlohaCare Medicaid	$108.00
Rate for Payer: AlohaCare Medicare	$108.00
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cash Price	$140.40
Rate for Payer: Devoted Health Medicare	$118.80
Rate for Payer: Hawaii Medical Service Association Commercial	$47.70
Rate for Payer: Hawaii Medical Service Association Medicare	$108.00
Rate for Payer: Hawaii Western Management Group Commercial	$205.20
Rate for Payer: Health Management Network Commercial	$183.60
Rate for Payer: Humana Medicare	$108.00
Rate for Payer: Kaiser Permanente Commercial	$194.40
Rate for Payer: Kaiser Permanente Medicaid	$110.16
Rate for Payer: Kaiser Permanente Medicare	$108.00
Rate for Payer: MDX Hawaii PPO	$209.52
Rate for Payer: Ohana Health Plan Medicaid	$108.00
Rate for Payer: Ohana Health Plan Medicare	$108.00
Rate for Payer: UnitedHealthcare Medicaid	$14.47
Rate for Payer: UnitedHealthcare Medicare	$108.00
Rate for Payer: University Health Alliance Commercial	$157.44

carvedilol 12.5 mg tablet [HHSC]

Facility

$10.84

Service Code	NDC 68084086501
Hospital Charge Code	2500147
Hospital Revenue Code	250
Min. Negotiated Rate	$5.42
Max. Negotiated Rate	$10.51
Rate for Payer: AlohaCare Medicaid	$5.42
Rate for Payer: AlohaCare Medicare	$5.42
Rate for Payer: Cash Price	$7.05
Rate for Payer: Devoted Health Medicare	$5.96
Rate for Payer: Hawaii Medical Service Association Medicare	$5.42
Rate for Payer: Hawaii Western Management Group Commercial	$10.30
Rate for Payer: Health Management Network Commercial	$9.21
Rate for Payer: Humana Medicare	$5.42
Rate for Payer: Kaiser Permanente Commercial	$9.76
Rate for Payer: Kaiser Permanente Medicaid	$5.53
Rate for Payer: Kaiser Permanente Medicare	$5.42
Rate for Payer: MDX Hawaii PPO	$10.51
Rate for Payer: Ohana Health Plan Medicaid	$5.42
Rate for Payer: Ohana Health Plan Medicare	$5.42
Rate for Payer: UnitedHealthcare Medicaid	$6.50
Rate for Payer: UnitedHealthcare Medicare	$5.42
Rate for Payer: University Health Alliance Commercial	$7.90

carvedilol 12.5 mg tablet [HHSC]

Facility

$10.84

Service Code	NDC 68084086501
Hospital Charge Code	2500147
Hospital Revenue Code	250
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$10.51
Rate for Payer: Cash Price	$7.05
Rate for Payer: Health Management Network Commercial	$9.21
Rate for Payer: Kaiser Permanente Commercial	$9.76
Rate for Payer: MDX Hawaii PPO	$10.51

carvedilol 12.5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904730761
Hospital Charge Code	2500147
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

carvedilol 12.5 mg tablet [HHSC]

Facility

$11.68

Service Code	NDC 00904630261
Hospital Charge Code	2500147
Hospital Revenue Code	250
Min. Negotiated Rate	$5.84
Max. Negotiated Rate	$11.33
Rate for Payer: AlohaCare Medicaid	$5.84
Rate for Payer: AlohaCare Medicare	$5.84
Rate for Payer: Cash Price	$7.59
Rate for Payer: Devoted Health Medicare	$6.42
Rate for Payer: Hawaii Medical Service Association Medicare	$5.84
Rate for Payer: Hawaii Western Management Group Commercial	$11.10
Rate for Payer: Health Management Network Commercial	$9.93
Rate for Payer: Humana Medicare	$5.84
Rate for Payer: Kaiser Permanente Commercial	$10.51
Rate for Payer: Kaiser Permanente Medicaid	$5.96
Rate for Payer: Kaiser Permanente Medicare	$5.84
Rate for Payer: MDX Hawaii PPO	$11.33
Rate for Payer: Ohana Health Plan Medicaid	$5.84
Rate for Payer: Ohana Health Plan Medicare	$5.84
Rate for Payer: UnitedHealthcare Medicaid	$7.01
Rate for Payer: UnitedHealthcare Medicare	$5.84
Rate for Payer: University Health Alliance Commercial	$8.51

carvedilol 12.5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904730761
Hospital Charge Code	2500147
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

carvedilol 12.5 mg tablet [HHSC]

Facility

$11.68

Service Code	NDC 00904630261
Hospital Charge Code	2500147
Hospital Revenue Code	250
Min. Negotiated Rate	$9.93
Max. Negotiated Rate	$11.33
Rate for Payer: Cash Price	$7.59
Rate for Payer: Health Management Network Commercial	$9.93
Rate for Payer: Kaiser Permanente Commercial	$10.51
Rate for Payer: MDX Hawaii PPO	$11.33

carvedilol 12.5 mg tablet [HHSC]

Facility

$11.88

Service Code	NDC 68001015100
Hospital Charge Code	2500147
Hospital Revenue Code	250
Min. Negotiated Rate	$10.10
Max. Negotiated Rate	$11.52
Rate for Payer: Cash Price	$7.72
Rate for Payer: Health Management Network Commercial	$10.10
Rate for Payer: Kaiser Permanente Commercial	$10.69
Rate for Payer: MDX Hawaii PPO	$11.52

carvedilol 12.5 mg tablet [HHSC]

Facility

$11.87

Service Code	NDC 51079093120
Hospital Charge Code	2500147
Hospital Revenue Code	250
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$11.51
Rate for Payer: AlohaCare Medicaid	$5.93
Rate for Payer: AlohaCare Medicare	$5.93
Rate for Payer: Cash Price	$7.72
Rate for Payer: Devoted Health Medicare	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$5.93
Rate for Payer: Hawaii Western Management Group Commercial	$11.28
Rate for Payer: Health Management Network Commercial	$10.09
Rate for Payer: Humana Medicare	$5.93
Rate for Payer: Kaiser Permanente Commercial	$10.68
Rate for Payer: Kaiser Permanente Medicaid	$6.05
Rate for Payer: Kaiser Permanente Medicare	$5.93
Rate for Payer: MDX Hawaii PPO	$11.51
Rate for Payer: Ohana Health Plan Medicaid	$5.93
Rate for Payer: Ohana Health Plan Medicare	$5.93
Rate for Payer: UnitedHealthcare Medicaid	$7.12
Rate for Payer: UnitedHealthcare Medicare	$5.93
Rate for Payer: University Health Alliance Commercial	$8.65

carvedilol 12.5 mg tablet [HHSC]

Facility

$11.87

Service Code	NDC 51079093120
Hospital Charge Code	2500147
Hospital Revenue Code	250
Min. Negotiated Rate	$10.09
Max. Negotiated Rate	$11.51
Rate for Payer: Cash Price	$7.72
Rate for Payer: Health Management Network Commercial	$10.09
Rate for Payer: Kaiser Permanente Commercial	$10.68
Rate for Payer: MDX Hawaii PPO	$11.51

Know your out-of-pocket cost for care.

All Charges