Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

dexmedeTOMIDine 200 mcg/2mL vial [HHSC]

Facility

$113.91

Service Code	NDC 16729023993
Hospital Charge Code	2500226
Hospital Revenue Code	250
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$110.49
Rate for Payer: AlohaCare Medicaid	$56.95
Rate for Payer: AlohaCare Medicare	$56.95
Rate for Payer: Cash Price	$74.04
Rate for Payer: Devoted Health Medicare	$62.65
Rate for Payer: Hawaii Medical Service Association Medicare	$56.95
Rate for Payer: Hawaii Western Management Group Commercial	$108.21
Rate for Payer: Health Management Network Commercial	$96.82
Rate for Payer: Humana Medicare	$56.95
Rate for Payer: Kaiser Permanente Commercial	$102.52
Rate for Payer: Kaiser Permanente Medicaid	$58.09
Rate for Payer: Kaiser Permanente Medicare	$56.95
Rate for Payer: MDX Hawaii PPO	$110.49
Rate for Payer: Ohana Health Plan Medicaid	$56.95
Rate for Payer: Ohana Health Plan Medicare	$56.95
Rate for Payer: UnitedHealthcare Medicaid	$68.35
Rate for Payer: UnitedHealthcare Medicare	$56.95
Rate for Payer: University Health Alliance Commercial	$83.03

dexmedeTOMIDine 200 mcg/2mL vial [HHSC]

Facility

$41.35

Service Code	NDC 70860060503
Hospital Charge Code	2500226
Hospital Revenue Code	250
Min. Negotiated Rate	$20.68
Max. Negotiated Rate	$40.11
Rate for Payer: AlohaCare Medicaid	$20.68
Rate for Payer: AlohaCare Medicare	$20.68
Rate for Payer: Cash Price	$26.88
Rate for Payer: Devoted Health Medicare	$22.74
Rate for Payer: Hawaii Medical Service Association Medicare	$20.68
Rate for Payer: Hawaii Western Management Group Commercial	$39.28
Rate for Payer: Health Management Network Commercial	$35.15
Rate for Payer: Humana Medicare	$20.68
Rate for Payer: Kaiser Permanente Commercial	$37.22
Rate for Payer: Kaiser Permanente Medicaid	$21.09
Rate for Payer: Kaiser Permanente Medicare	$20.68
Rate for Payer: MDX Hawaii PPO	$40.11
Rate for Payer: Ohana Health Plan Medicaid	$20.68
Rate for Payer: Ohana Health Plan Medicare	$20.68
Rate for Payer: UnitedHealthcare Medicaid	$24.81
Rate for Payer: UnitedHealthcare Medicare	$20.68
Rate for Payer: University Health Alliance Commercial	$30.14

dexmedeTOMIDine 200 mcg/2mL vial [HHSC]

Facility

$113.91

Service Code	NDC 16729023993
Hospital Charge Code	2500226
Hospital Revenue Code	250
Min. Negotiated Rate	$96.82
Max. Negotiated Rate	$110.49
Rate for Payer: Cash Price	$74.04
Rate for Payer: Health Management Network Commercial	$96.82
Rate for Payer: Kaiser Permanente Commercial	$102.52
Rate for Payer: MDX Hawaii PPO	$110.49

dexmedeTOMIDine 200 mcg/2mL vial [HHSC]

Facility

$40.36

Service Code	NDC 66794023042
Hospital Charge Code	2500226
Hospital Revenue Code	250
Min. Negotiated Rate	$20.18
Max. Negotiated Rate	$39.15
Rate for Payer: AlohaCare Medicaid	$20.18
Rate for Payer: AlohaCare Medicare	$20.18
Rate for Payer: Cash Price	$26.23
Rate for Payer: Devoted Health Medicare	$22.20
Rate for Payer: Hawaii Medical Service Association Medicare	$20.18
Rate for Payer: Hawaii Western Management Group Commercial	$38.34
Rate for Payer: Health Management Network Commercial	$34.31
Rate for Payer: Humana Medicare	$20.18
Rate for Payer: Kaiser Permanente Commercial	$36.32
Rate for Payer: Kaiser Permanente Medicaid	$20.58
Rate for Payer: Kaiser Permanente Medicare	$20.18
Rate for Payer: MDX Hawaii PPO	$39.15
Rate for Payer: Ohana Health Plan Medicaid	$20.18
Rate for Payer: Ohana Health Plan Medicare	$20.18
Rate for Payer: UnitedHealthcare Medicaid	$24.22
Rate for Payer: UnitedHealthcare Medicare	$20.18
Rate for Payer: University Health Alliance Commercial	$29.42

dexmedeTOMIDine 400 mcg/100 mL NS premix [HHSC]

Facility

$434.51

Service Code	HCPCS J3490
Hospital Charge Code	2501068
Hospital Revenue Code	636
Min. Negotiated Rate	$217.25
Max. Negotiated Rate	$421.47
Rate for Payer: AlohaCare Medicaid	$217.25
Rate for Payer: AlohaCare Medicare	$217.25
Rate for Payer: Cash Price	$282.43
Rate for Payer: Devoted Health Medicare	$238.98
Rate for Payer: Hawaii Medical Service Association Medicare	$217.25
Rate for Payer: Hawaii Western Management Group Commercial	$412.78
Rate for Payer: Health Management Network Commercial	$369.33
Rate for Payer: Humana Medicare	$217.25
Rate for Payer: Kaiser Permanente Commercial	$391.06
Rate for Payer: Kaiser Permanente Medicaid	$221.60
Rate for Payer: Kaiser Permanente Medicare	$217.25
Rate for Payer: MDX Hawaii PPO	$421.47
Rate for Payer: Ohana Health Plan Medicaid	$217.25
Rate for Payer: Ohana Health Plan Medicare	$217.25
Rate for Payer: UnitedHealthcare Medicaid	$260.71
Rate for Payer: UnitedHealthcare Medicare	$217.25
Rate for Payer: University Health Alliance Commercial	$316.71

dexmedeTOMIDine 400 mcg/100 mL NS premix [HHSC]

Facility

$434.51

Service Code	HCPCS J3490
Hospital Charge Code	2501068
Hospital Revenue Code	250
Min. Negotiated Rate	$369.33
Max. Negotiated Rate	$421.47
Rate for Payer: Cash Price	$282.43
Rate for Payer: Health Management Network Commercial	$369.33
Rate for Payer: Kaiser Permanente Commercial	$391.06
Rate for Payer: MDX Hawaii PPO	$421.47

dextrose 10%-water 500 ml [HHSC]

Facility

$13.01

Service Code	NDC 00264752010
Hospital Charge Code	2500228
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

dextrose 10%-water 500 ml [HHSC]

Facility

$13.01

Service Code	NDC 00264752010
Hospital Charge Code	2500228
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

dextrose 40% gel oral [HHSC]

Facility

$21.96

Service Code	NDC 00574007030
Hospital Charge Code	2500359
Hospital Revenue Code	250
Min. Negotiated Rate	$18.67
Max. Negotiated Rate	$21.30
Rate for Payer: Cash Price	$14.27
Rate for Payer: Health Management Network Commercial	$18.67
Rate for Payer: Kaiser Permanente Commercial	$19.76
Rate for Payer: MDX Hawaii PPO	$21.30

dextrose 40% gel oral [HHSC]

Facility

$21.96

Service Code	NDC 00574007030
Hospital Charge Code	2500359
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$21.30
Rate for Payer: AlohaCare Medicaid	$10.98
Rate for Payer: AlohaCare Medicare	$10.98
Rate for Payer: Cash Price	$14.27
Rate for Payer: Devoted Health Medicare	$12.08
Rate for Payer: Hawaii Medical Service Association Medicare	$10.98
Rate for Payer: Hawaii Western Management Group Commercial	$20.86
Rate for Payer: Health Management Network Commercial	$18.67
Rate for Payer: Humana Medicare	$10.98
Rate for Payer: Kaiser Permanente Commercial	$19.76
Rate for Payer: Kaiser Permanente Medicaid	$11.20
Rate for Payer: Kaiser Permanente Medicare	$10.98
Rate for Payer: MDX Hawaii PPO	$21.30
Rate for Payer: Ohana Health Plan Medicaid	$10.98
Rate for Payer: Ohana Health Plan Medicare	$10.98
Rate for Payer: UnitedHealthcare Medicaid	$13.18
Rate for Payer: UnitedHealthcare Medicare	$10.98
Rate for Payer: University Health Alliance Commercial	$16.01

dextrose 40% gel oral [HHSC]

Facility

$21.96

Service Code	NDC 00574006930
Hospital Charge Code	2500359
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$21.30
Rate for Payer: AlohaCare Medicaid	$10.98
Rate for Payer: AlohaCare Medicare	$10.98
Rate for Payer: Cash Price	$14.27
Rate for Payer: Devoted Health Medicare	$12.08
Rate for Payer: Hawaii Medical Service Association Medicare	$10.98
Rate for Payer: Hawaii Western Management Group Commercial	$20.86
Rate for Payer: Health Management Network Commercial	$18.67
Rate for Payer: Humana Medicare	$10.98
Rate for Payer: Kaiser Permanente Commercial	$19.76
Rate for Payer: Kaiser Permanente Medicaid	$11.20
Rate for Payer: Kaiser Permanente Medicare	$10.98
Rate for Payer: MDX Hawaii PPO	$21.30
Rate for Payer: Ohana Health Plan Medicaid	$10.98
Rate for Payer: Ohana Health Plan Medicare	$10.98
Rate for Payer: UnitedHealthcare Medicaid	$13.18
Rate for Payer: UnitedHealthcare Medicare	$10.98
Rate for Payer: University Health Alliance Commercial	$16.01

dextrose 40% gel oral [HHSC]

Facility

$21.96

Service Code	NDC 00574006930
Hospital Charge Code	2500359
Hospital Revenue Code	250
Min. Negotiated Rate	$18.67
Max. Negotiated Rate	$21.30
Rate for Payer: Cash Price	$14.27
Rate for Payer: Health Management Network Commercial	$18.67
Rate for Payer: Kaiser Permanente Commercial	$19.76
Rate for Payer: MDX Hawaii PPO	$21.30

dextrose 50%-water 50ml syringe [HHSC]

Facility

$68.31

Service Code	NDC 76329330101
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$58.06
Max. Negotiated Rate	$66.26
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$58.06
Rate for Payer: Kaiser Permanente Commercial	$61.48
Rate for Payer: MDX Hawaii PPO	$66.26

dextrose 50%-water 50ml syringe [HHSC]

Facility

$119.67

Service Code	NDC 76329330201
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$59.84
Max. Negotiated Rate	$116.08
Rate for Payer: AlohaCare Medicaid	$59.84
Rate for Payer: AlohaCare Medicare	$59.84
Rate for Payer: Cash Price	$77.79
Rate for Payer: Devoted Health Medicare	$65.82
Rate for Payer: Hawaii Medical Service Association Medicare	$59.84
Rate for Payer: Hawaii Western Management Group Commercial	$113.69
Rate for Payer: Health Management Network Commercial	$101.72
Rate for Payer: Humana Medicare	$59.84
Rate for Payer: Kaiser Permanente Commercial	$107.70
Rate for Payer: Kaiser Permanente Medicaid	$61.03
Rate for Payer: Kaiser Permanente Medicare	$59.84
Rate for Payer: MDX Hawaii PPO	$116.08
Rate for Payer: Ohana Health Plan Medicaid	$59.84
Rate for Payer: Ohana Health Plan Medicare	$59.84
Rate for Payer: UnitedHealthcare Medicaid	$71.80
Rate for Payer: UnitedHealthcare Medicare	$59.84
Rate for Payer: University Health Alliance Commercial	$87.23

dextrose 50%-water 50ml syringe [HHSC]

Facility

$119.67

Service Code	NDC 76329330201
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$101.72
Max. Negotiated Rate	$116.08
Rate for Payer: Cash Price	$77.79
Rate for Payer: Health Management Network Commercial	$101.72
Rate for Payer: Kaiser Permanente Commercial	$107.70
Rate for Payer: MDX Hawaii PPO	$116.08

dextrose 50%-water 50ml syringe [HHSC]

Facility

$117.09

Service Code	NDC 00409751716
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$99.53
Max. Negotiated Rate	$113.58
Rate for Payer: Cash Price	$76.11
Rate for Payer: Health Management Network Commercial	$99.53
Rate for Payer: Kaiser Permanente Commercial	$105.38
Rate for Payer: MDX Hawaii PPO	$113.58

dextrose 50%-water 50ml syringe [HHSC]

Facility

$68.31

Service Code	NDC 76329330101
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$34.16
Max. Negotiated Rate	$66.26
Rate for Payer: AlohaCare Medicaid	$34.16
Rate for Payer: AlohaCare Medicare	$34.16
Rate for Payer: Cash Price	$44.40
Rate for Payer: Devoted Health Medicare	$37.57
Rate for Payer: Hawaii Medical Service Association Medicare	$34.16
Rate for Payer: Hawaii Western Management Group Commercial	$64.89
Rate for Payer: Health Management Network Commercial	$58.06
Rate for Payer: Humana Medicare	$34.16
Rate for Payer: Kaiser Permanente Commercial	$61.48
Rate for Payer: Kaiser Permanente Medicaid	$34.84
Rate for Payer: Kaiser Permanente Medicare	$34.16
Rate for Payer: MDX Hawaii PPO	$66.26
Rate for Payer: Ohana Health Plan Medicaid	$34.16
Rate for Payer: Ohana Health Plan Medicare	$34.16
Rate for Payer: UnitedHealthcare Medicaid	$40.99
Rate for Payer: UnitedHealthcare Medicare	$34.16
Rate for Payer: University Health Alliance Commercial	$49.79

dextrose 50%-water 50ml syringe [HHSC]

Facility

$117.09

Service Code	NDC 00409751716
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$58.55
Max. Negotiated Rate	$113.58
Rate for Payer: AlohaCare Medicaid	$58.55
Rate for Payer: AlohaCare Medicare	$58.55
Rate for Payer: Cash Price	$76.11
Rate for Payer: Devoted Health Medicare	$64.40
Rate for Payer: Hawaii Medical Service Association Medicare	$58.55
Rate for Payer: Hawaii Western Management Group Commercial	$111.24
Rate for Payer: Health Management Network Commercial	$99.53
Rate for Payer: Humana Medicare	$58.55
Rate for Payer: Kaiser Permanente Commercial	$105.38
Rate for Payer: Kaiser Permanente Medicaid	$59.72
Rate for Payer: Kaiser Permanente Medicare	$58.55
Rate for Payer: MDX Hawaii PPO	$113.58
Rate for Payer: Ohana Health Plan Medicaid	$58.55
Rate for Payer: Ohana Health Plan Medicare	$58.55
Rate for Payer: UnitedHealthcare Medicaid	$70.25
Rate for Payer: UnitedHealthcare Medicare	$58.55
Rate for Payer: University Health Alliance Commercial	$85.35

dextrose 50%-water 50ml syringe [HHSC]

Facility

$110.11

Service Code	NDC 00409490234
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$55.05
Max. Negotiated Rate	$106.81
Rate for Payer: AlohaCare Medicaid	$55.05
Rate for Payer: AlohaCare Medicare	$55.05
Rate for Payer: Cash Price	$71.57
Rate for Payer: Devoted Health Medicare	$60.56
Rate for Payer: Hawaii Medical Service Association Medicare	$55.05
Rate for Payer: Hawaii Western Management Group Commercial	$104.60
Rate for Payer: Health Management Network Commercial	$93.59
Rate for Payer: Humana Medicare	$55.05
Rate for Payer: Kaiser Permanente Commercial	$99.10
Rate for Payer: Kaiser Permanente Medicaid	$56.16
Rate for Payer: Kaiser Permanente Medicare	$55.05
Rate for Payer: MDX Hawaii PPO	$106.81
Rate for Payer: Ohana Health Plan Medicaid	$55.05
Rate for Payer: Ohana Health Plan Medicare	$55.05
Rate for Payer: UnitedHealthcare Medicaid	$66.07
Rate for Payer: UnitedHealthcare Medicare	$55.05
Rate for Payer: University Health Alliance Commercial	$80.26

dextrose 50%-water 50ml syringe [HHSC]

Facility

$110.11

Service Code	NDC 00409490234
Hospital Charge Code	2500360
Hospital Revenue Code	250
Min. Negotiated Rate	$93.59
Max. Negotiated Rate	$106.81
Rate for Payer: Cash Price	$71.57
Rate for Payer: Health Management Network Commercial	$93.59
Rate for Payer: Kaiser Permanente Commercial	$99.10
Rate for Payer: MDX Hawaii PPO	$106.81

dextrose 5%- lactated ringers 1000 ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7121
Hospital Charge Code	2500229
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
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	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.01
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

dextrose 5%- lactated ringers 1000 ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7121
Hospital Charge Code	2500229
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

dextrose 5%-water 1000ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7060
Hospital Charge Code	2500231
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
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	$2.03
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
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

dextrose 5%-water 1000ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7060
Hospital Charge Code	2500231
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

dextrose 5% -water 100 ml [HHSC]

Facility

$8.53

Service Code	HCPCS J7060
Hospital Charge Code	2500230
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$8.27
Rate for Payer: AlohaCare Medicaid	$4.26
Rate for Payer: AlohaCare Medicare	$4.26
Rate for Payer: Cash Price	$5.54
Rate for Payer: Cash Price	$5.54
Rate for Payer: Devoted Health Medicare	$4.69
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Medicare	$4.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Western Management Group Commercial	$8.10
Rate for Payer: Health Management Network Commercial	$7.25
Rate for Payer: Humana Medicare	$4.26
Rate for Payer: Kaiser Permanente Commercial	$7.68
Rate for Payer: Kaiser Permanente Medicaid	$4.35
Rate for Payer: Kaiser Permanente Medicare	$4.26
Rate for Payer: MDX Hawaii PPO	$8.27
Rate for Payer: Ohana Health Plan Medicaid	$4.26
Rate for Payer: Ohana Health Plan Medicare	$4.26
Rate for Payer: UnitedHealthcare Medicaid	$5.12
Rate for Payer: UnitedHealthcare Medicare	$4.26
Rate for Payer: University Health Alliance Commercial	$6.22

Know your out-of-pocket cost for care.

All Charges