Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

chlordiazePOXIDE 25 mg capsule [HHSC]

Facility

$4.42

Service Code	NDC 60687080701
Hospital Charge Code	2500172
Hospital Revenue Code	250
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$4.29
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Management Network Commercial	$3.76
Rate for Payer: Kaiser Permanente Commercial	$3.98
Rate for Payer: MDX Hawaii PPO	$4.29

chlordiazePOXIDE 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00555015902
Hospital Charge Code	2500172
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

chlordiazePOXIDE 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 00555015902
Hospital Charge Code	2500172
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

chlorhexidine 4% liquid 118ml [HHSC]

Facility

$62.27

Service Code	NDC 67618020004
Hospital Charge Code	2500173
Hospital Revenue Code	250
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$60.40
Rate for Payer: AlohaCare Medicaid	$31.14
Rate for Payer: AlohaCare Medicare	$31.14
Rate for Payer: Cash Price	$40.48
Rate for Payer: Devoted Health Medicare	$34.25
Rate for Payer: Hawaii Medical Service Association Medicare	$31.14
Rate for Payer: Hawaii Western Management Group Commercial	$59.16
Rate for Payer: Health Management Network Commercial	$52.93
Rate for Payer: Humana Medicare	$31.14
Rate for Payer: Kaiser Permanente Commercial	$56.04
Rate for Payer: Kaiser Permanente Medicaid	$31.76
Rate for Payer: Kaiser Permanente Medicare	$31.14
Rate for Payer: MDX Hawaii PPO	$60.40
Rate for Payer: Ohana Health Plan Medicaid	$31.14
Rate for Payer: Ohana Health Plan Medicare	$31.14
Rate for Payer: UnitedHealthcare Medicaid	$37.36
Rate for Payer: UnitedHealthcare Medicare	$31.14
Rate for Payer: University Health Alliance Commercial	$45.39

chlorhexidine 4% liquid 118ml [HHSC]

Facility

$41.87

Service Code	NDC 52380127204
Hospital Charge Code	2500173
Hospital Revenue Code	250
Min. Negotiated Rate	$20.93
Max. Negotiated Rate	$40.61
Rate for Payer: AlohaCare Medicaid	$20.93
Rate for Payer: AlohaCare Medicare	$20.93
Rate for Payer: Cash Price	$27.22
Rate for Payer: Devoted Health Medicare	$23.03
Rate for Payer: Hawaii Medical Service Association Medicare	$20.93
Rate for Payer: Hawaii Western Management Group Commercial	$39.78
Rate for Payer: Health Management Network Commercial	$35.59
Rate for Payer: Humana Medicare	$20.93
Rate for Payer: Kaiser Permanente Commercial	$37.68
Rate for Payer: Kaiser Permanente Medicaid	$21.35
Rate for Payer: Kaiser Permanente Medicare	$20.93
Rate for Payer: MDX Hawaii PPO	$40.61
Rate for Payer: Ohana Health Plan Medicaid	$20.93
Rate for Payer: Ohana Health Plan Medicare	$20.93
Rate for Payer: UnitedHealthcare Medicaid	$25.12
Rate for Payer: UnitedHealthcare Medicare	$20.93
Rate for Payer: University Health Alliance Commercial	$30.52

chlorhexidine 4% liquid 118ml [HHSC]

Facility

$20.74

Service Code	NDC 00234057504
Hospital Charge Code	2500173
Hospital Revenue Code	250
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$20.12
Rate for Payer: AlohaCare Medicaid	$10.37
Rate for Payer: AlohaCare Medicare	$10.37
Rate for Payer: Cash Price	$13.48
Rate for Payer: Devoted Health Medicare	$11.41
Rate for Payer: Hawaii Medical Service Association Medicare	$10.37
Rate for Payer: Hawaii Western Management Group Commercial	$19.70
Rate for Payer: Health Management Network Commercial	$17.63
Rate for Payer: Humana Medicare	$10.37
Rate for Payer: Kaiser Permanente Commercial	$18.67
Rate for Payer: Kaiser Permanente Medicaid	$10.58
Rate for Payer: Kaiser Permanente Medicare	$10.37
Rate for Payer: MDX Hawaii PPO	$20.12
Rate for Payer: Ohana Health Plan Medicaid	$10.37
Rate for Payer: Ohana Health Plan Medicare	$10.37
Rate for Payer: UnitedHealthcare Medicaid	$12.44
Rate for Payer: UnitedHealthcare Medicare	$10.37
Rate for Payer: University Health Alliance Commercial	$15.12

chlorhexidine 4% liquid 118ml [HHSC]

Facility

$20.74

Service Code	NDC 00234057504
Hospital Charge Code	2500173
Hospital Revenue Code	250
Min. Negotiated Rate	$17.63
Max. Negotiated Rate	$20.12
Rate for Payer: Cash Price	$13.48
Rate for Payer: Health Management Network Commercial	$17.63
Rate for Payer: Kaiser Permanente Commercial	$18.67
Rate for Payer: MDX Hawaii PPO	$20.12

chlorhexidine 4% liquid 118ml [HHSC]

Facility

$41.87

Service Code	NDC 52380127204
Hospital Charge Code	2500173
Hospital Revenue Code	250
Min. Negotiated Rate	$35.59
Max. Negotiated Rate	$40.61
Rate for Payer: Cash Price	$27.22
Rate for Payer: Health Management Network Commercial	$35.59
Rate for Payer: Kaiser Permanente Commercial	$37.68
Rate for Payer: MDX Hawaii PPO	$40.61

chlorhexidine 4% liquid 118ml [HHSC]

Facility

$62.27

Service Code	NDC 67618020004
Hospital Charge Code	2500173
Hospital Revenue Code	250
Min. Negotiated Rate	$52.93
Max. Negotiated Rate	$60.40
Rate for Payer: Cash Price	$40.48
Rate for Payer: Health Management Network Commercial	$52.93
Rate for Payer: Kaiser Permanente Commercial	$56.04
Rate for Payer: MDX Hawaii PPO	$60.40

chlorhexidine gluc 0.12% oral rinse 15 mL [HHSC]

Facility

$12.68

Service Code	HCPCS A9270
Hospital Charge Code	2501045
Hospital Revenue Code	637
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$12.30
Rate for Payer: AlohaCare Medicaid	$6.34
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.34
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cash Price	$8.24
Rate for Payer: Devoted Health Medicare	$6.97
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Medical Service Association Medicare	$6.34
Rate for Payer: Hawaii Western Management Group Commercial	$12.36
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$10.78
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Humana Medicare	$6.34
Rate for Payer: Kaiser Permanente Commercial	$11.41
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: Kaiser Permanente Medicaid	$6.64
Rate for Payer: Kaiser Permanente Medicaid	$6.47
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: Kaiser Permanente Medicare	$6.34
Rate for Payer: MDX Hawaii PPO	$12.62
Rate for Payer: MDX Hawaii PPO	$12.30
Rate for Payer: Ohana Health Plan Medicaid	$6.34
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.34
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicare	$6.34
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48
Rate for Payer: University Health Alliance Commercial	$9.24

chlorhexidine gluc 0.12% oral rinse 15 mL [HHSC]

Facility

$13.01

Service Code	HCPCS A9270
Hospital Charge Code	2501045
Hospital Revenue Code	250
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cash Price	$8.24
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Health Management Network Commercial	$10.78
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: Kaiser Permanente Commercial	$11.41
Rate for Payer: MDX Hawaii PPO	$12.30
Rate for Payer: MDX Hawaii PPO	$12.62

chlorhexidine gluconate 4% 473ml [HHSC]

Facility

$74.28

Service Code	NDC 67618020016
Hospital Charge Code	2501210
Hospital Revenue Code	250
Min. Negotiated Rate	$37.14
Max. Negotiated Rate	$72.05
Rate for Payer: AlohaCare Medicaid	$37.14
Rate for Payer: AlohaCare Medicare	$37.14
Rate for Payer: Cash Price	$48.28
Rate for Payer: Devoted Health Medicare	$40.85
Rate for Payer: Hawaii Medical Service Association Medicare	$37.14
Rate for Payer: Hawaii Western Management Group Commercial	$70.57
Rate for Payer: Health Management Network Commercial	$63.14
Rate for Payer: Humana Medicare	$37.14
Rate for Payer: Kaiser Permanente Commercial	$66.85
Rate for Payer: Kaiser Permanente Medicaid	$37.88
Rate for Payer: Kaiser Permanente Medicare	$37.14
Rate for Payer: MDX Hawaii PPO	$72.05
Rate for Payer: Ohana Health Plan Medicaid	$37.14
Rate for Payer: Ohana Health Plan Medicare	$37.14
Rate for Payer: UnitedHealthcare Medicaid	$44.57
Rate for Payer: UnitedHealthcare Medicare	$37.14
Rate for Payer: University Health Alliance Commercial	$54.14

chlorhexidine gluconate 4% 473ml [HHSC]

Facility

$74.28

Service Code	NDC 67618020016
Hospital Charge Code	2501210
Hospital Revenue Code	250
Min. Negotiated Rate	$63.14
Max. Negotiated Rate	$72.05
Rate for Payer: Cash Price	$48.28
Rate for Payer: Health Management Network Commercial	$63.14
Rate for Payer: Kaiser Permanente Commercial	$66.85
Rate for Payer: MDX Hawaii PPO	$72.05

chlorhexidine gluconate 4% 473ml [HHSC]

Facility

$65.42

Service Code	NDC 16571011148
Hospital Charge Code	2501210
Hospital Revenue Code	250
Min. Negotiated Rate	$32.71
Max. Negotiated Rate	$63.46
Rate for Payer: AlohaCare Medicaid	$32.71
Rate for Payer: AlohaCare Medicare	$32.71
Rate for Payer: Cash Price	$42.52
Rate for Payer: Devoted Health Medicare	$35.98
Rate for Payer: Hawaii Medical Service Association Medicare	$32.71
Rate for Payer: Hawaii Western Management Group Commercial	$62.15
Rate for Payer: Health Management Network Commercial	$55.61
Rate for Payer: Humana Medicare	$32.71
Rate for Payer: Kaiser Permanente Commercial	$58.88
Rate for Payer: Kaiser Permanente Medicaid	$33.36
Rate for Payer: Kaiser Permanente Medicare	$32.71
Rate for Payer: MDX Hawaii PPO	$63.46
Rate for Payer: Ohana Health Plan Medicaid	$32.71
Rate for Payer: Ohana Health Plan Medicare	$32.71
Rate for Payer: UnitedHealthcare Medicaid	$39.25
Rate for Payer: UnitedHealthcare Medicare	$32.71
Rate for Payer: University Health Alliance Commercial	$47.68

chlorhexidine gluconate 4% 473ml [HHSC]

Facility

$65.42

Service Code	NDC 16571011148
Hospital Charge Code	2501210
Hospital Revenue Code	250
Min. Negotiated Rate	$55.61
Max. Negotiated Rate	$63.46
Rate for Payer: Cash Price	$42.52
Rate for Payer: Health Management Network Commercial	$55.61
Rate for Payer: Kaiser Permanente Commercial	$58.88
Rate for Payer: MDX Hawaii PPO	$63.46

chlorhexidine gluconate 4% 946ml [HHSC]

Facility

$86.95

Service Code	NDC 67618020030
Hospital Charge Code	2500876
Hospital Revenue Code	250
Min. Negotiated Rate	$43.48
Max. Negotiated Rate	$84.34
Rate for Payer: AlohaCare Medicaid	$43.48
Rate for Payer: AlohaCare Medicare	$43.48
Rate for Payer: Cash Price	$56.52
Rate for Payer: Devoted Health Medicare	$47.82
Rate for Payer: Hawaii Medical Service Association Medicare	$43.48
Rate for Payer: Hawaii Western Management Group Commercial	$82.60
Rate for Payer: Health Management Network Commercial	$73.91
Rate for Payer: Humana Medicare	$43.48
Rate for Payer: Kaiser Permanente Commercial	$78.25
Rate for Payer: Kaiser Permanente Medicaid	$44.34
Rate for Payer: Kaiser Permanente Medicare	$43.48
Rate for Payer: MDX Hawaii PPO	$84.34
Rate for Payer: Ohana Health Plan Medicaid	$43.48
Rate for Payer: Ohana Health Plan Medicare	$43.48
Rate for Payer: UnitedHealthcare Medicaid	$52.17
Rate for Payer: UnitedHealthcare Medicare	$43.48
Rate for Payer: University Health Alliance Commercial	$63.38

chlorhexidine gluconate 4% 946ml [HHSC]

Facility

$75.13

Service Code	NDC 00234057532
Hospital Charge Code	2500876
Hospital Revenue Code	250
Min. Negotiated Rate	$63.86
Max. Negotiated Rate	$72.88
Rate for Payer: Cash Price	$48.83
Rate for Payer: Health Management Network Commercial	$63.86
Rate for Payer: Kaiser Permanente Commercial	$67.62
Rate for Payer: MDX Hawaii PPO	$72.88

chlorhexidine gluconate 4% 946ml [HHSC]

Facility

$75.13

Service Code	NDC 00234057532
Hospital Charge Code	2500876
Hospital Revenue Code	250
Min. Negotiated Rate	$37.56
Max. Negotiated Rate	$72.88
Rate for Payer: AlohaCare Medicaid	$37.56
Rate for Payer: AlohaCare Medicare	$37.56
Rate for Payer: Cash Price	$48.83
Rate for Payer: Devoted Health Medicare	$41.32
Rate for Payer: Hawaii Medical Service Association Medicare	$37.56
Rate for Payer: Hawaii Western Management Group Commercial	$71.37
Rate for Payer: Health Management Network Commercial	$63.86
Rate for Payer: Humana Medicare	$37.56
Rate for Payer: Kaiser Permanente Commercial	$67.62
Rate for Payer: Kaiser Permanente Medicaid	$38.32
Rate for Payer: Kaiser Permanente Medicare	$37.56
Rate for Payer: MDX Hawaii PPO	$72.88
Rate for Payer: Ohana Health Plan Medicaid	$37.56
Rate for Payer: Ohana Health Plan Medicare	$37.56
Rate for Payer: UnitedHealthcare Medicaid	$45.08
Rate for Payer: UnitedHealthcare Medicare	$37.56
Rate for Payer: University Health Alliance Commercial	$54.76

chlorhexidine gluconate 4% 946ml [HHSC]

Facility

$86.95

Service Code	NDC 67618020030
Hospital Charge Code	2500876
Hospital Revenue Code	250
Min. Negotiated Rate	$73.91
Max. Negotiated Rate	$84.34
Rate for Payer: Cash Price	$56.52
Rate for Payer: Health Management Network Commercial	$73.91
Rate for Payer: Kaiser Permanente Commercial	$78.25
Rate for Payer: MDX Hawaii PPO	$84.34

Chloride (Arterial) POCT

Facility

$63.00

Service Code	HCPCS 82435
Hospital Charge Code	9364701
Hospital Revenue Code	301
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$6.35
Rate for Payer: Hawaii Medical Service Association Commercial	$5.75
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.67
Rate for Payer: Hawaii Western Management Group Commercial	$4.60
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$6.35
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$11.88

Chloride (Arterial) POCT

Facility

$63.00

Service Code	HCPCS 82435
Hospital Charge Code	9364701
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Chloride FSI

Facility

$63.00

Service Code	HCPCS 82435
Hospital Charge Code	8404523
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Chloride FSI

Facility

$63.00

Service Code	HCPCS 82435
Hospital Charge Code	8404523
Hospital Revenue Code	301
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$6.35
Rate for Payer: Hawaii Medical Service Association Commercial	$5.75
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.67
Rate for Payer: Hawaii Western Management Group Commercial	$4.60
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$6.35
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$11.88

Chloride, Urine Random FSI

Facility

$118.00

Service Code	HCPCS 87493
Hospital Charge Code	8228851
Hospital Revenue Code	301
Min. Negotiated Rate	$37.27
Max. Negotiated Rate	$114.46
Rate for Payer: AlohaCare Medicaid	$59.00
Rate for Payer: AlohaCare Medicare	$59.00
Rate for Payer: Cash Price	$76.70
Rate for Payer: Cash Price	$76.70
Rate for Payer: Devoted Health Medicare	$64.90
Rate for Payer: Hawaii Medical Service Association ABD	$50.27
Rate for Payer: Hawaii Medical Service Association Commercial	$46.59
Rate for Payer: Hawaii Medical Service Association Medicare	$59.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$37.27
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Humana Medicare	$59.00
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: Kaiser Permanente Medicare	$59.00
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: Ohana Health Plan Medicaid	$59.00
Rate for Payer: Ohana Health Plan Medicare	$59.00
Rate for Payer: UnitedHealthcare Medicaid	$50.27
Rate for Payer: UnitedHealthcare Medicare	$59.00
Rate for Payer: University Health Alliance Commercial	$93.00

Chloride, Urine Random FSI

Facility

$118.00

Service Code	HCPCS 87493
Hospital Charge Code	8228851
Hospital Revenue Code	301
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$76.70
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: MDX Hawaii PPO	$114.46

Know your out-of-pocket cost for care.

All Charges