Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

DISTAL RADIUS PLATE 2.4MM VOLAR LEFT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043800
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: AlohaCare Medicaid	$3,750.00
Rate for Payer: AlohaCare Medicare	$3,750.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Devoted Health Medicare	$4,125.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Humana Medicare	$3,750.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: Kaiser Permanente Medicare	$3,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: Ohana Health Plan Medicaid	$3,750.00
Rate for Payer: Ohana Health Plan Medicare	$3,750.00
Rate for Payer: UnitedHealthcare Medicare	$3,750.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR LEFT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043800
Hospital Revenue Code	278
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT NARROW

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043797
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: AlohaCare Medicaid	$3,750.00
Rate for Payer: AlohaCare Medicare	$3,750.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Devoted Health Medicare	$4,125.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Humana Medicare	$3,750.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: Kaiser Permanente Medicare	$3,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: Ohana Health Plan Medicaid	$3,750.00
Rate for Payer: Ohana Health Plan Medicare	$3,750.00
Rate for Payer: UnitedHealthcare Medicare	$3,750.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT NARROW

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043797
Hospital Revenue Code	278
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043799
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: AlohaCare Medicaid	$3,750.00
Rate for Payer: AlohaCare Medicare	$3,750.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Devoted Health Medicare	$4,125.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Humana Medicare	$3,750.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: Kaiser Permanente Medicare	$3,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: Ohana Health Plan Medicaid	$3,750.00
Rate for Payer: Ohana Health Plan Medicare	$3,750.00
Rate for Payer: UnitedHealthcare Medicare	$3,750.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043799
Hospital Revenue Code	278
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR TEMPLATES

Facility

$563.00

Service Code	HCPCS C1713
Hospital Charge Code	13043798
Hospital Revenue Code	278
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$315.28

DISTAL RADIUS PLATE 2.4MM VOLAR TEMPLATES

Facility

$563.00

Service Code	HCPCS C1713
Hospital Charge Code	13043798
Hospital Revenue Code	278
Min. Negotiated Rate	$315.28
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$315.28

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 65862059401
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$13.24
Rate for Payer: Cash Price	$8.87
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: MDX Hawaii PPO	$13.24

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 65862059401
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$13.24
Rate for Payer: AlohaCare Medicaid	$6.83
Rate for Payer: AlohaCare Medicare	$6.83
Rate for Payer: Cash Price	$8.87
Rate for Payer: Devoted Health Medicare	$7.51
Rate for Payer: Hawaii Medical Service Association Medicare	$6.83
Rate for Payer: Hawaii Western Management Group Commercial	$12.97
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Humana Medicare	$6.83
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: Kaiser Permanente Medicaid	$6.96
Rate for Payer: Kaiser Permanente Medicare	$6.83
Rate for Payer: MDX Hawaii PPO	$13.24
Rate for Payer: Ohana Health Plan Medicaid	$6.83
Rate for Payer: Ohana Health Plan Medicare	$6.83
Rate for Payer: UnitedHealthcare Medicaid	$8.19
Rate for Payer: UnitedHealthcare Medicare	$6.83
Rate for Payer: University Health Alliance Commercial	$9.95

divalproex ER 250 mg tablet [HHSC]

Facility

$3.45

Service Code	NDC 50268025915
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.35
Rate for Payer: AlohaCare Medicaid	$1.73
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$2.24
Rate for Payer: Devoted Health Medicare	$1.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.28
Rate for Payer: Health Management Network Commercial	$2.93
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: Kaiser Permanente Medicaid	$1.76
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$3.35
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$2.51

divalproex ER 250 mg tablet [HHSC]

Facility

$13.61

Service Code	NDC 68084031001
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$13.20
Rate for Payer: AlohaCare Medicaid	$6.80
Rate for Payer: AlohaCare Medicare	$6.80
Rate for Payer: Cash Price	$8.85
Rate for Payer: Devoted Health Medicare	$7.49
Rate for Payer: Hawaii Medical Service Association Medicare	$6.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.93
Rate for Payer: Health Management Network Commercial	$11.57
Rate for Payer: Humana Medicare	$6.80
Rate for Payer: Kaiser Permanente Commercial	$12.25
Rate for Payer: Kaiser Permanente Medicaid	$6.94
Rate for Payer: Kaiser Permanente Medicare	$6.80
Rate for Payer: MDX Hawaii PPO	$13.20
Rate for Payer: Ohana Health Plan Medicaid	$6.80
Rate for Payer: Ohana Health Plan Medicare	$6.80
Rate for Payer: UnitedHealthcare Medicaid	$8.17
Rate for Payer: UnitedHealthcare Medicare	$6.80
Rate for Payer: University Health Alliance Commercial	$9.92

divalproex ER 250 mg tablet [HHSC]

Facility

$13.61

Service Code	NDC 68084031001
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$13.20
Rate for Payer: Cash Price	$8.85
Rate for Payer: Health Management Network Commercial	$11.57
Rate for Payer: Kaiser Permanente Commercial	$12.25
Rate for Payer: MDX Hawaii PPO	$13.20

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 68001010500
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$13.24
Rate for Payer: AlohaCare Medicaid	$6.83
Rate for Payer: AlohaCare Medicare	$6.83
Rate for Payer: Cash Price	$8.87
Rate for Payer: Devoted Health Medicare	$7.51
Rate for Payer: Hawaii Medical Service Association Medicare	$6.83
Rate for Payer: Hawaii Western Management Group Commercial	$12.97
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Humana Medicare	$6.83
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: Kaiser Permanente Medicaid	$6.96
Rate for Payer: Kaiser Permanente Medicare	$6.83
Rate for Payer: MDX Hawaii PPO	$13.24
Rate for Payer: Ohana Health Plan Medicaid	$6.83
Rate for Payer: Ohana Health Plan Medicare	$6.83
Rate for Payer: UnitedHealthcare Medicaid	$8.19
Rate for Payer: UnitedHealthcare Medicare	$6.83
Rate for Payer: University Health Alliance Commercial	$9.95

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 68001010500
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$13.24
Rate for Payer: Cash Price	$8.87
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: MDX Hawaii PPO	$13.24

divalproex ER 250 mg tablet [HHSC]

Facility

$3.45

Service Code	NDC 50268025915
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$3.35
Rate for Payer: Cash Price	$2.24
Rate for Payer: Health Management Network Commercial	$2.93
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: MDX Hawaii PPO	$3.35

DLCO ANY METHOD CHARGE

Facility

$455.00

Service Code	HCPCS 94729
Hospital Charge Code	8243388
Hospital Revenue Code	460
Min. Negotiated Rate	$386.75
Max. Negotiated Rate	$441.35
Rate for Payer: Cash Price	$295.75
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: Kaiser Permanente Commercial	$409.50
Rate for Payer: MDX Hawaii PPO	$441.35

DLCO ANY METHOD CHARGE

Facility

$455.00

Service Code	HCPCS 94729
Hospital Charge Code	8243388
Hospital Revenue Code	460
Min. Negotiated Rate	$31.25
Max. Negotiated Rate	$441.35
Rate for Payer: AlohaCare Medicaid	$227.50
Rate for Payer: AlohaCare Medicare	$227.50
Rate for Payer: Cash Price	$295.75
Rate for Payer: Cash Price	$295.75
Rate for Payer: Devoted Health Medicare	$250.25
Rate for Payer: Hawaii Medical Service Association ABD	$31.25
Rate for Payer: Hawaii Medical Service Association Medicare	$227.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$44.88
Rate for Payer: Hawaii Western Management Group Commercial	$432.25
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: Humana Medicare	$227.50
Rate for Payer: Kaiser Permanente Commercial	$409.50
Rate for Payer: Kaiser Permanente Medicaid	$232.05
Rate for Payer: Kaiser Permanente Medicare	$227.50
Rate for Payer: MDX Hawaii PPO	$441.35
Rate for Payer: Ohana Health Plan Medicaid	$227.50
Rate for Payer: Ohana Health Plan Medicare	$227.50
Rate for Payer: UnitedHealthcare Medicaid	$31.25
Rate for Payer: UnitedHealthcare Medicare	$227.50
Rate for Payer: University Health Alliance Commercial	$331.65

DLS5583A-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12516201
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583A-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12516201
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583B-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12561268
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583B-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12561268
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583C-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12564297
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583C-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12564297
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583D-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12564298
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

Know your out-of-pocket cost for care.

All Charges