Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

D5W-NACL 0.9% 1000ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7042
Hospital Charge Code	2500239
Hospital Revenue Code	636
Min. Negotiated Rate	$1.36
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: Cash Price	$8.46
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association ABD	$1.36
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.36
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 0.9% 1000ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7042
Hospital Charge Code	2500239
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 0.9%- KCL 20 mEq/L [HHSC]

Facility

$16.68

Service Code	HCPCS J3480
Hospital Charge Code	2500238
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$16.18
Rate for Payer: AlohaCare Medicaid	$8.34
Rate for Payer: AlohaCare Medicaid	$29.28
Rate for Payer: AlohaCare Medicare	$29.28
Rate for Payer: AlohaCare Medicare	$8.34
Rate for Payer: Cash Price	$38.06
Rate for Payer: Cash Price	$10.84
Rate for Payer: Cash Price	$10.84
Rate for Payer: Cash Price	$38.06
Rate for Payer: Devoted Health Medicare	$9.17
Rate for Payer: Devoted Health Medicare	$32.21
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$29.28
Rate for Payer: Hawaii Medical Service Association Medicare	$8.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$15.85
Rate for Payer: Hawaii Western Management Group Commercial	$55.63
Rate for Payer: Health Management Network Commercial	$49.78
Rate for Payer: Health Management Network Commercial	$14.18
Rate for Payer: Humana Medicare	$8.34
Rate for Payer: Humana Medicare	$29.28
Rate for Payer: Kaiser Permanente Commercial	$15.01
Rate for Payer: Kaiser Permanente Commercial	$52.70
Rate for Payer: Kaiser Permanente Medicaid	$29.87
Rate for Payer: Kaiser Permanente Medicaid	$8.51
Rate for Payer: Kaiser Permanente Medicare	$8.34
Rate for Payer: Kaiser Permanente Medicare	$29.28
Rate for Payer: MDX Hawaii PPO	$16.18
Rate for Payer: MDX Hawaii PPO	$56.80
Rate for Payer: Ohana Health Plan Medicaid	$29.28
Rate for Payer: Ohana Health Plan Medicaid	$8.34
Rate for Payer: Ohana Health Plan Medicare	$8.34
Rate for Payer: Ohana Health Plan Medicare	$29.28
Rate for Payer: UnitedHealthcare Medicaid	$35.14
Rate for Payer: UnitedHealthcare Medicaid	$10.01
Rate for Payer: UnitedHealthcare Medicare	$8.34
Rate for Payer: UnitedHealthcare Medicare	$29.28
Rate for Payer: University Health Alliance Commercial	$12.16
Rate for Payer: University Health Alliance Commercial	$42.68

D5W-NACL 0.9%- KCL 20 mEq/L [HHSC]

Facility

$16.68

Service Code	HCPCS J3480
Hospital Charge Code	2500238
Hospital Revenue Code	250
Min. Negotiated Rate	$14.18
Max. Negotiated Rate	$16.18
Rate for Payer: Cash Price	$10.84
Rate for Payer: Cash Price	$38.06
Rate for Payer: Health Management Network Commercial	$14.18
Rate for Payer: Health Management Network Commercial	$49.78
Rate for Payer: Kaiser Permanente Commercial	$15.01
Rate for Payer: Kaiser Permanente Commercial	$52.70
Rate for Payer: MDX Hawaii PPO	$56.80
Rate for Payer: MDX Hawaii PPO	$16.18

dantrolene 250 mg vial [HHSC]

Facility

$5,667.76

Service Code	NDC 42367054032
Hospital Charge Code	2500215
Hospital Revenue Code	250
Min. Negotiated Rate	$4,817.60
Max. Negotiated Rate	$5,497.73
Rate for Payer: Cash Price	$3,684.04
Rate for Payer: Health Management Network Commercial	$4,817.60
Rate for Payer: Kaiser Permanente Commercial	$5,100.98
Rate for Payer: MDX Hawaii PPO	$5,497.73

dantrolene 250 mg vial [HHSC]

Facility

$5,667.76

Service Code	NDC 42367054032
Hospital Charge Code	2500215
Hospital Revenue Code	250
Min. Negotiated Rate	$2,833.88
Max. Negotiated Rate	$5,497.73
Rate for Payer: AlohaCare Medicaid	$2,833.88
Rate for Payer: AlohaCare Medicare	$2,833.88
Rate for Payer: Cash Price	$3,684.04
Rate for Payer: Devoted Health Medicare	$3,117.27
Rate for Payer: Hawaii Medical Service Association Medicare	$2,833.88
Rate for Payer: Hawaii Western Management Group Commercial	$5,384.37
Rate for Payer: Health Management Network Commercial	$4,817.60
Rate for Payer: Humana Medicare	$2,833.88
Rate for Payer: Kaiser Permanente Commercial	$5,100.98
Rate for Payer: Kaiser Permanente Medicaid	$2,890.56
Rate for Payer: Kaiser Permanente Medicare	$2,833.88
Rate for Payer: MDX Hawaii PPO	$5,497.73
Rate for Payer: Ohana Health Plan Medicaid	$2,833.88
Rate for Payer: Ohana Health Plan Medicare	$2,833.88
Rate for Payer: UnitedHealthcare Medicaid	$3,400.66
Rate for Payer: UnitedHealthcare Medicare	$2,833.88
Rate for Payer: University Health Alliance Commercial	$4,131.23

DAPTOmycin 500 mg vial [HHSC]

Facility

$1,359.27

Service Code	HCPCS J0878
Hospital Charge Code	2500979
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1,318.49
Rate for Payer: AlohaCare Medicaid	$679.63
Rate for Payer: AlohaCare Medicare	$679.63
Rate for Payer: Cash Price	$883.53
Rate for Payer: Cash Price	$883.53
Rate for Payer: Devoted Health Medicare	$747.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Medicare	$679.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.91
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.31
Rate for Payer: Health Management Network Commercial	$1,155.38
Rate for Payer: Humana Medicare	$679.63
Rate for Payer: Kaiser Permanente Commercial	$1,223.34
Rate for Payer: Kaiser Permanente Medicaid	$693.23
Rate for Payer: Kaiser Permanente Medicare	$679.63
Rate for Payer: MDX Hawaii PPO	$1,318.49
Rate for Payer: Ohana Health Plan Medicaid	$679.63
Rate for Payer: Ohana Health Plan Medicare	$679.63
Rate for Payer: UnitedHealthcare Medicaid	$815.56
Rate for Payer: UnitedHealthcare Medicare	$679.63
Rate for Payer: University Health Alliance Commercial	$990.77

DAPTOmycin 500 mg vial [HHSC]

Facility

$1,359.27

Service Code	HCPCS J0878
Hospital Charge Code	2500979
Hospital Revenue Code	250
Min. Negotiated Rate	$1,155.38
Max. Negotiated Rate	$1,318.49
Rate for Payer: Cash Price	$883.53
Rate for Payer: Health Management Network Commercial	$1,155.38
Rate for Payer: Kaiser Permanente Commercial	$1,223.34
Rate for Payer: MDX Hawaii PPO	$1,318.49

DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL

Facility

$8,656.00

Service Code	HCPCS 11005
Hospital Charge Code	8803193
Hospital Revenue Code	361
Min. Negotiated Rate	$7,357.60
Max. Negotiated Rate	$8,396.32
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Health Management Network Commercial	$7,357.60
Rate for Payer: Kaiser Permanente Commercial	$7,790.40
Rate for Payer: MDX Hawaii PPO	$8,396.32

DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL

Facility

$8,656.00

Service Code	HCPCS 11005
Hospital Charge Code	8803193
Hospital Revenue Code	361
Min. Negotiated Rate	$566.13
Max. Negotiated Rate	$8,396.32
Rate for Payer: AlohaCare Medicaid	$4,328.00
Rate for Payer: AlohaCare Medicare	$4,328.00
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Devoted Health Medicare	$4,760.80
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,328.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Health Management Network Commercial	$7,357.60
Rate for Payer: Humana Medicare	$4,328.00
Rate for Payer: Kaiser Permanente Commercial	$7,790.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,328.00
Rate for Payer: MDX Hawaii PPO	$8,396.32
Rate for Payer: Ohana Health Plan Medicaid	$4,328.00
Rate for Payer: Ohana Health Plan Medicare	$4,328.00
Rate for Payer: UnitedHealthcare Medicaid	$566.13
Rate for Payer: UnitedHealthcare Medicare	$4,328.00
Rate for Payer: University Health Alliance Commercial	$6,309.36

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC

Facility

$16,827.36

Service Code	MSDRG 744
Min. Negotiated Rate	$16,827.36
Max. Negotiated Rate	$16,827.36
Rate for Payer: Hawaii Medical Service Association Commercial	$16,827.36

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC

Facility

$16,827.36

Service Code	MSDRG 745
Min. Negotiated Rate	$16,827.36
Max. Negotiated Rate	$16,827.36
Rate for Payer: Hawaii Medical Service Association Commercial	$16,827.36

D-Dimer, Quantitative REF

Facility

$145.00

Service Code	HCPCS 85379
Hospital Charge Code	8160152
Hospital Revenue Code	305
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65

D-Dimer, Quantitative REF

Facility

$145.00

Service Code	HCPCS 85379
Hospital Charge Code	8160152
Hospital Revenue Code	305
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association ABD	$14.06
Rate for Payer: Hawaii Medical Service Association Commercial	$12.72
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.76
Rate for Payer: Hawaii Western Management Group Commercial	$10.18
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicaid	$14.06
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$26.31

Declot PICC, CVC Nursing

Facility

$1,263.00

Service Code	HCPCS 36593
Hospital Charge Code	11934638
Hospital Revenue Code	450
Min. Negotiated Rate	$1,073.55
Max. Negotiated Rate	$1,225.11
Rate for Payer: Cash Price	$820.95
Rate for Payer: Health Management Network Commercial	$1,073.55
Rate for Payer: Kaiser Permanente Commercial	$1,136.70
Rate for Payer: MDX Hawaii PPO	$1,225.11

Declot PICC, CVC Nursing

Facility

$1,263.00

Service Code	HCPCS 36593
Hospital Charge Code	11934638
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,389.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$631.50
Rate for Payer: Cash Price	$820.95
Rate for Payer: Cash Price	$820.95
Rate for Payer: Cash Price	$820.95
Rate for Payer: Devoted Health Medicare	$694.65
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 Medicare	$631.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,199.85
Rate for Payer: Health Management Network Commercial	$1,073.55
Rate for Payer: Humana Medicare	$631.50
Rate for Payer: Kaiser Permanente Commercial	$1,136.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$631.50
Rate for Payer: MDX Hawaii PPO	$1,225.11
Rate for Payer: Ohana Health Plan Medicaid	$631.50
Rate for Payer: Ohana Health Plan Medicare	$631.50
Rate for Payer: UnitedHealthcare Medicare	$631.50
Rate for Payer: University Health Alliance Commercial	$920.60

DECOMPRESSION, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISC, ANY METHOD UTILIZING NEEDLE-BASED TECHNIQUE TO REMOVE DISC MATERIAL UNDER FLUOROSCOPIC IMAGING OR OTHER FORM OF INDIRECT VISUALIZATION, WITH DISCOGRAPHY AND/OR EPIDURAL INJECTION(S) AT THE TREATED LEVEL(S), WHEN PERFORMED, SINGLE OR MULTIPLE LEVELS, LUMBAR

Facility

$24,500.00

Service Code	CPT 62287
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$24,500.00
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$24,500.00

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$27,790.64

Service Code	MSDRG 056
Min. Negotiated Rate	$27,790.64
Max. Negotiated Rate	$27,790.64
Rate for Payer: Hawaii Medical Service Association Commercial	$27,790.64

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$27,790.64

Service Code	MSDRG 057
Min. Negotiated Rate	$27,790.64
Max. Negotiated Rate	$27,790.64
Rate for Payer: Hawaii Medical Service Association Commercial	$27,790.64

DELTA TERRY-NET ADHESIVE BLACK 1.25X15YD 1/RL

Facility

$103.00

Hospital Charge Code	12957403
Hospital Revenue Code	270
Min. Negotiated Rate	$51.50
Max. Negotiated Rate	$99.91
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$51.50
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$56.65
Rate for Payer: Hawaii Medical Service Association Medicare	$51.50
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$51.50
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$51.50
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$51.50
Rate for Payer: Ohana Health Plan Medicare	$51.50
Rate for Payer: UnitedHealthcare Medicare	$51.50
Rate for Payer: University Health Alliance Commercial	$75.08

DELTA TERRY-NET ADHESIVE BLACK 1.25X15YD 1/RL

Facility

$103.00

Hospital Charge Code	12957403
Hospital Revenue Code	270
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$66.95
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: MDX Hawaii PPO	$99.91

DEMO EVAL INH NEB USE CHARGE

Facility

$262.00

Service Code	HCPCS 94664
Hospital Charge Code	8243402
Hospital Revenue Code	410
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$170.30
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: MDX Hawaii PPO	$254.14

DEMO EVAL INH NEB USE CHARGE

Facility

$262.00

Service Code	HCPCS 94664
Hospital Charge Code	8243402
Hospital Revenue Code	410
Min. Negotiated Rate	$14.35
Max. Negotiated Rate	$279.65
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$131.00
Rate for Payer: Cash Price	$170.30
Rate for Payer: Cash Price	$170.30
Rate for Payer: Devoted Health Medicare	$144.10
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$131.00
Rate for Payer: Hawaii Western Management Group Commercial	$248.90
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Humana Medicare	$131.00
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: Kaiser Permanente Medicaid	$133.62
Rate for Payer: Kaiser Permanente Medicare	$131.00
Rate for Payer: MDX Hawaii PPO	$254.14
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$131.00
Rate for Payer: UnitedHealthcare Medicaid	$14.35
Rate for Payer: UnitedHealthcare Medicare	$131.00
Rate for Payer: University Health Alliance Commercial	$190.97

DENTAL AND ORAL DISEASES WITH CC

Facility

$21,442.14

Service Code	MSDRG 158
Min. Negotiated Rate	$21,442.14
Max. Negotiated Rate	$21,442.14
Rate for Payer: Hawaii Medical Service Association Commercial	$21,442.14

DENTAL AND ORAL DISEASES WITH MCC

Facility

$21,442.14

Service Code	MSDRG 157
Min. Negotiated Rate	$21,442.14
Max. Negotiated Rate	$21,442.14
Rate for Payer: Hawaii Medical Service Association Commercial	$21,442.14

Know your out-of-pocket cost for care.

All Charges