Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$187.40

Service Code	NDC 00065039602
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$93.70
Max. Negotiated Rate	$181.78
Rate for Payer: AlohaCare Medicaid	$93.70
Rate for Payer: AlohaCare Medicare	$93.70
Rate for Payer: Cash Price	$121.81
Rate for Payer: Devoted Health Medicare	$103.07
Rate for Payer: Hawaii Medical Service Association Medicare	$93.70
Rate for Payer: Hawaii Western Management Group Commercial	$178.03
Rate for Payer: Health Management Network Commercial	$159.29
Rate for Payer: Humana Medicare	$93.70
Rate for Payer: Kaiser Permanente Commercial	$168.66
Rate for Payer: Kaiser Permanente Medicaid	$95.57
Rate for Payer: Kaiser Permanente Medicare	$93.70
Rate for Payer: MDX Hawaii PPO	$181.78
Rate for Payer: Ohana Health Plan Medicaid	$93.70
Rate for Payer: Ohana Health Plan Medicare	$93.70
Rate for Payer: UnitedHealthcare Medicaid	$112.44
Rate for Payer: UnitedHealthcare Medicare	$93.70
Rate for Payer: University Health Alliance Commercial	$136.60

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$187.40

Service Code	NDC 00065039602
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$159.29
Max. Negotiated Rate	$181.78
Rate for Payer: Cash Price	$121.81
Rate for Payer: Health Management Network Commercial	$159.29
Rate for Payer: Kaiser Permanente Commercial	$168.66
Rate for Payer: MDX Hawaii PPO	$181.78

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$88.37

Service Code	NDC 61314039601
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$44.19
Max. Negotiated Rate	$85.72
Rate for Payer: AlohaCare Medicaid	$44.19
Rate for Payer: AlohaCare Medicare	$44.19
Rate for Payer: Cash Price	$57.44
Rate for Payer: Devoted Health Medicare	$48.60
Rate for Payer: Hawaii Medical Service Association Medicare	$44.19
Rate for Payer: Hawaii Western Management Group Commercial	$83.95
Rate for Payer: Health Management Network Commercial	$75.11
Rate for Payer: Humana Medicare	$44.19
Rate for Payer: Kaiser Permanente Commercial	$79.53
Rate for Payer: Kaiser Permanente Medicaid	$45.07
Rate for Payer: Kaiser Permanente Medicare	$44.19
Rate for Payer: MDX Hawaii PPO	$85.72
Rate for Payer: Ohana Health Plan Medicaid	$44.19
Rate for Payer: Ohana Health Plan Medicare	$44.19
Rate for Payer: UnitedHealthcare Medicaid	$53.02
Rate for Payer: UnitedHealthcare Medicare	$44.19
Rate for Payer: University Health Alliance Commercial	$64.41

Cyclosporine FSI

Facility

$206.00

Service Code	HCPCS 80158
Hospital Charge Code	8117900
Hospital Revenue Code	301
Min. Negotiated Rate	$175.10
Max. Negotiated Rate	$199.82
Rate for Payer: Cash Price	$133.90
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: MDX Hawaii PPO	$199.82

Cyclosporine FSI

Facility

$206.00

Service Code	HCPCS 80158
Hospital Charge Code	8117900
Hospital Revenue Code	301
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$199.82
Rate for Payer: AlohaCare Medicaid	$103.00
Rate for Payer: AlohaCare Medicare	$103.00
Rate for Payer: Cash Price	$133.90
Rate for Payer: Cash Price	$133.90
Rate for Payer: Devoted Health Medicare	$113.30
Rate for Payer: Hawaii Medical Service Association ABD	$24.95
Rate for Payer: Hawaii Medical Service Association Commercial	$22.56
Rate for Payer: Hawaii Medical Service Association Medicare	$103.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.20
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Humana Medicare	$103.00
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: Kaiser Permanente Medicaid	$105.06
Rate for Payer: Kaiser Permanente Medicare	$103.00
Rate for Payer: MDX Hawaii PPO	$199.82
Rate for Payer: Ohana Health Plan Medicaid	$103.00
Rate for Payer: Ohana Health Plan Medicare	$103.00
Rate for Payer: UnitedHealthcare Medicaid	$24.95
Rate for Payer: UnitedHealthcare Medicare	$103.00
Rate for Payer: University Health Alliance Commercial	$46.68

cyproheptadine 4 mg tablet [HHSC]

Facility

$5.93

Service Code	NDC 50742019001
Hospital Charge Code	2501003
Hospital Revenue Code	250
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$5.75
Rate for Payer: Cash Price	$3.85
Rate for Payer: Health Management Network Commercial	$5.04
Rate for Payer: Kaiser Permanente Commercial	$5.34
Rate for Payer: MDX Hawaii PPO	$5.75

cyproheptadine 4 mg tablet [HHSC]

Facility

$5.93

Service Code	NDC 70710111001
Hospital Charge Code	2501003
Hospital Revenue Code	250
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$5.75
Rate for Payer: Cash Price	$3.85
Rate for Payer: Health Management Network Commercial	$5.04
Rate for Payer: Kaiser Permanente Commercial	$5.34
Rate for Payer: MDX Hawaii PPO	$5.75

cyproheptadine 4 mg tablet [HHSC]

Facility

$5.93

Service Code	NDC 70710111001
Hospital Charge Code	2501003
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$5.75
Rate for Payer: AlohaCare Medicaid	$2.96
Rate for Payer: AlohaCare Medicare	$2.96
Rate for Payer: Cash Price	$3.85
Rate for Payer: Devoted Health Medicare	$3.26
Rate for Payer: Hawaii Medical Service Association Medicare	$2.96
Rate for Payer: Hawaii Western Management Group Commercial	$5.63
Rate for Payer: Health Management Network Commercial	$5.04
Rate for Payer: Humana Medicare	$2.96
Rate for Payer: Kaiser Permanente Commercial	$5.34
Rate for Payer: Kaiser Permanente Medicaid	$3.02
Rate for Payer: Kaiser Permanente Medicare	$2.96
Rate for Payer: MDX Hawaii PPO	$5.75
Rate for Payer: Ohana Health Plan Medicaid	$2.96
Rate for Payer: Ohana Health Plan Medicare	$2.96
Rate for Payer: UnitedHealthcare Medicaid	$3.56
Rate for Payer: UnitedHealthcare Medicare	$2.96
Rate for Payer: University Health Alliance Commercial	$4.32

cyproheptadine 4 mg tablet [HHSC]

Facility

$5.93

Service Code	NDC 50742019001
Hospital Charge Code	2501003
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$5.75
Rate for Payer: AlohaCare Medicaid	$2.96
Rate for Payer: AlohaCare Medicare	$2.96
Rate for Payer: Cash Price	$3.85
Rate for Payer: Devoted Health Medicare	$3.26
Rate for Payer: Hawaii Medical Service Association Medicare	$2.96
Rate for Payer: Hawaii Western Management Group Commercial	$5.63
Rate for Payer: Health Management Network Commercial	$5.04
Rate for Payer: Humana Medicare	$2.96
Rate for Payer: Kaiser Permanente Commercial	$5.34
Rate for Payer: Kaiser Permanente Medicaid	$3.02
Rate for Payer: Kaiser Permanente Medicare	$2.96
Rate for Payer: MDX Hawaii PPO	$5.75
Rate for Payer: Ohana Health Plan Medicaid	$2.96
Rate for Payer: Ohana Health Plan Medicare	$2.96
Rate for Payer: UnitedHealthcare Medicaid	$3.56
Rate for Payer: UnitedHealthcare Medicare	$2.96
Rate for Payer: University Health Alliance Commercial	$4.32

CYSTOURETHROSCOPY (SEPARATE PROCEDURE)

Facility

$2,837.00

Service Code	CPT 52000
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$672.48
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 Non-ABD	$407.95
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18

CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE

Facility

$7,085.00

Service Code	CPT 52281
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,085.00
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)

Facility

$11,119.00

Service Code	CPT 52235
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,119.00
Rate for Payer: AlohaCare Medicaid	$1,030.55
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$11,119.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)

Facility

$7,085.00

Service Code	CPT 52332
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,085.00
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC

Facility

$7,085.00

Service Code	CPT 52351
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,085.00
Rate for Payer: AlohaCare Medicaid	$1,030.55
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)

Facility

$10,679.55

Service Code	CPT 52353
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$1,379.34
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: University Health Alliance Commercial	$10,679.55

D5W-NaCl 0.2% 500 mL [HHSC]

Facility

$66.76

Service Code	NDC 00264761610
Hospital Charge Code	2500235
Hospital Revenue Code	250
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$64.76
Rate for Payer: AlohaCare Medicaid	$33.38
Rate for Payer: AlohaCare Medicare	$33.38
Rate for Payer: Cash Price	$43.39
Rate for Payer: Devoted Health Medicare	$36.72
Rate for Payer: Hawaii Medical Service Association Medicare	$33.38
Rate for Payer: Hawaii Western Management Group Commercial	$63.42
Rate for Payer: Health Management Network Commercial	$56.75
Rate for Payer: Humana Medicare	$33.38
Rate for Payer: Kaiser Permanente Commercial	$60.08
Rate for Payer: Kaiser Permanente Medicaid	$34.05
Rate for Payer: Kaiser Permanente Medicare	$33.38
Rate for Payer: MDX Hawaii PPO	$64.76
Rate for Payer: Ohana Health Plan Medicaid	$33.38
Rate for Payer: Ohana Health Plan Medicare	$33.38
Rate for Payer: UnitedHealthcare Medicaid	$40.06
Rate for Payer: UnitedHealthcare Medicare	$33.38
Rate for Payer: University Health Alliance Commercial	$48.66

D5W-NaCl 0.2% 500 mL [HHSC]

Facility

$66.76

Service Code	NDC 00264761610
Hospital Charge Code	2500235
Hospital Revenue Code	250
Min. Negotiated Rate	$56.75
Max. Negotiated Rate	$64.76
Rate for Payer: Cash Price	$43.39
Rate for Payer: Health Management Network Commercial	$56.75
Rate for Payer: Kaiser Permanente Commercial	$60.08
Rate for Payer: MDX Hawaii PPO	$64.76

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$30.64

Service Code	NDC 00409792609
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$15.32
Max. Negotiated Rate	$29.72
Rate for Payer: AlohaCare Medicaid	$15.32
Rate for Payer: AlohaCare Medicare	$15.32
Rate for Payer: Cash Price	$19.92
Rate for Payer: Devoted Health Medicare	$16.85
Rate for Payer: Hawaii Medical Service Association Medicare	$15.32
Rate for Payer: Hawaii Western Management Group Commercial	$29.11
Rate for Payer: Health Management Network Commercial	$26.04
Rate for Payer: Humana Medicare	$15.32
Rate for Payer: Kaiser Permanente Commercial	$27.58
Rate for Payer: Kaiser Permanente Medicaid	$15.63
Rate for Payer: Kaiser Permanente Medicare	$15.32
Rate for Payer: MDX Hawaii PPO	$29.72
Rate for Payer: Ohana Health Plan Medicaid	$15.32
Rate for Payer: Ohana Health Plan Medicare	$15.32
Rate for Payer: UnitedHealthcare Medicaid	$18.38
Rate for Payer: UnitedHealthcare Medicare	$15.32
Rate for Payer: University Health Alliance Commercial	$22.33

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$30.64

Service Code	NDC 00409792609
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$26.04
Max. Negotiated Rate	$29.72
Rate for Payer: Cash Price	$19.92
Rate for Payer: Health Management Network Commercial	$26.04
Rate for Payer: Kaiser Permanente Commercial	$27.58
Rate for Payer: MDX Hawaii PPO	$29.72

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$13.01

Service Code	NDC 00264761200
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.62
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.46
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$12.36
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: Kaiser Permanente Medicaid	$6.64
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.62
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicaid	$7.81
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$13.01

Service Code	NDC 00264761200
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$8.46
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: MDX Hawaii PPO	$12.62

D5W-NACL 0.45%-KCL 10 mEq/L [HHSC]

Facility

$15.57

Service Code	HCPCS J3480
Hospital Charge Code	2500236
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$15.10
Rate for Payer: AlohaCare Medicaid	$7.79
Rate for Payer: AlohaCare Medicare	$7.79
Rate for Payer: Cash Price	$10.12
Rate for Payer: Cash Price	$10.12
Rate for Payer: Devoted Health Medicare	$8.56
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$7.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$14.79
Rate for Payer: Health Management Network Commercial	$13.23
Rate for Payer: Humana Medicare	$7.79
Rate for Payer: Kaiser Permanente Commercial	$14.01
Rate for Payer: Kaiser Permanente Medicaid	$7.94
Rate for Payer: Kaiser Permanente Medicare	$7.79
Rate for Payer: MDX Hawaii PPO	$15.10
Rate for Payer: Ohana Health Plan Medicaid	$7.79
Rate for Payer: Ohana Health Plan Medicare	$7.79
Rate for Payer: UnitedHealthcare Medicaid	$9.34
Rate for Payer: UnitedHealthcare Medicare	$7.79
Rate for Payer: University Health Alliance Commercial	$11.35

D5W-NACL 0.45%-KCL 10 mEq/L [HHSC]

Facility

$15.57

Service Code	HCPCS J3480
Hospital Charge Code	2500236
Hospital Revenue Code	250
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$15.10
Rate for Payer: Cash Price	$10.12
Rate for Payer: Health Management Network Commercial	$13.23
Rate for Payer: Kaiser Permanente Commercial	$14.01
Rate for Payer: MDX Hawaii PPO	$15.10

D5W-NACL 0.45%-KCL 20 mEq/L [HHSC]

Facility

$14.96

Service Code	HCPCS J3480
Hospital Charge Code	2500878
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$14.51
Rate for Payer: AlohaCare Medicaid	$7.48
Rate for Payer: AlohaCare Medicare	$7.48
Rate for Payer: Cash Price	$9.72
Rate for Payer: Cash Price	$9.72
Rate for Payer: Devoted Health Medicare	$8.23
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$7.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$14.21
Rate for Payer: Health Management Network Commercial	$12.72
Rate for Payer: Humana Medicare	$7.48
Rate for Payer: Kaiser Permanente Commercial	$13.46
Rate for Payer: Kaiser Permanente Medicaid	$7.63
Rate for Payer: Kaiser Permanente Medicare	$7.48
Rate for Payer: MDX Hawaii PPO	$14.51
Rate for Payer: Ohana Health Plan Medicaid	$7.48
Rate for Payer: Ohana Health Plan Medicare	$7.48
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$7.48
Rate for Payer: University Health Alliance Commercial	$10.90

D5W-NACL 0.45%-KCL 20 mEq/L [HHSC]

Facility

$14.96

Service Code	HCPCS J3480
Hospital Charge Code	2500878
Hospital Revenue Code	250
Min. Negotiated Rate	$12.72
Max. Negotiated Rate	$14.51
Rate for Payer: Cash Price	$9.72
Rate for Payer: Health Management Network Commercial	$12.72
Rate for Payer: Kaiser Permanente Commercial	$13.46
Rate for Payer: MDX Hawaii PPO	$14.51

Know your out-of-pocket cost for care.

All Charges