Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Drug Detection Panel, Meconium, Qualitative FSI 3000364

Facility

$408.00

Service Code	HCPCS 80364
Hospital Charge Code	10654747
Hospital Revenue Code	300
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

Drug Detection Panel, Meconium, Qualitative FSI 3000481

Facility

$1,118.00

Service Code	HCPCS G0481
Hospital Charge Code	10655268
Hospital Revenue Code	300
Min. Negotiated Rate	$73.79
Max. Negotiated Rate	$1,084.46
Rate for Payer: AlohaCare Medicaid	$559.00
Rate for Payer: AlohaCare Medicare	$559.00
Rate for Payer: Cash Price	$726.70
Rate for Payer: Cash Price	$726.70
Rate for Payer: Devoted Health Medicare	$614.90
Rate for Payer: Hawaii Medical Service Association Commercial	$195.74
Rate for Payer: Hawaii Medical Service Association Medicare	$559.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,062.10
Rate for Payer: Health Management Network Commercial	$950.30
Rate for Payer: Humana Medicare	$559.00
Rate for Payer: Kaiser Permanente Commercial	$1,006.20
Rate for Payer: Kaiser Permanente Medicaid	$570.18
Rate for Payer: Kaiser Permanente Medicare	$559.00
Rate for Payer: MDX Hawaii PPO	$1,084.46
Rate for Payer: Ohana Health Plan Medicaid	$559.00
Rate for Payer: Ohana Health Plan Medicare	$559.00
Rate for Payer: UnitedHealthcare Medicaid	$73.79
Rate for Payer: UnitedHealthcare Medicare	$559.00
Rate for Payer: University Health Alliance Commercial	$814.91

Drug Detection Panel, Meconium, Qualitative FSI 3000481

Facility

$1,118.00

Service Code	HCPCS G0481
Hospital Charge Code	10655268
Hospital Revenue Code	300
Min. Negotiated Rate	$950.30
Max. Negotiated Rate	$1,084.46
Rate for Payer: Cash Price	$726.70
Rate for Payer: Health Management Network Commercial	$950.30
Rate for Payer: Kaiser Permanente Commercial	$1,006.20
Rate for Payer: MDX Hawaii PPO	$1,084.46

Drug Screen POC

Facility

$149.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	8041483
Hospital Revenue Code	301
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Drug Screen POC

Facility

$149.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	8041483
Hospital Revenue Code	301
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$19.03
Rate for Payer: Hawaii Medical Service Association Commercial	$15.75
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.11
Rate for Payer: Hawaii Western Management Group Commercial	$12.60
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$27.68

DULoxetine 20 mg capsule [HHSC]

Facility

$49.44

Service Code	HCPCS J8499
Hospital Charge Code	2501062
Hospital Revenue Code	636
Min. Negotiated Rate	$24.72
Max. Negotiated Rate	$47.96
Rate for Payer: AlohaCare Medicaid	$24.72
Rate for Payer: AlohaCare Medicaid	$21.86
Rate for Payer: AlohaCare Medicare	$24.72
Rate for Payer: AlohaCare Medicare	$21.86
Rate for Payer: Cash Price	$28.42
Rate for Payer: Cash Price	$32.14
Rate for Payer: Devoted Health Medicare	$24.05
Rate for Payer: Devoted Health Medicare	$27.19
Rate for Payer: Hawaii Medical Service Association Medicare	$21.86
Rate for Payer: Hawaii Medical Service Association Medicare	$24.72
Rate for Payer: Hawaii Western Management Group Commercial	$46.97
Rate for Payer: Hawaii Western Management Group Commercial	$41.53
Rate for Payer: Health Management Network Commercial	$42.02
Rate for Payer: Health Management Network Commercial	$37.16
Rate for Payer: Humana Medicare	$21.86
Rate for Payer: Humana Medicare	$24.72
Rate for Payer: Kaiser Permanente Commercial	$39.35
Rate for Payer: Kaiser Permanente Commercial	$44.50
Rate for Payer: Kaiser Permanente Medicaid	$22.30
Rate for Payer: Kaiser Permanente Medicaid	$25.21
Rate for Payer: Kaiser Permanente Medicare	$24.72
Rate for Payer: Kaiser Permanente Medicare	$21.86
Rate for Payer: MDX Hawaii PPO	$47.96
Rate for Payer: MDX Hawaii PPO	$42.41
Rate for Payer: Ohana Health Plan Medicaid	$24.72
Rate for Payer: Ohana Health Plan Medicaid	$21.86
Rate for Payer: Ohana Health Plan Medicare	$21.86
Rate for Payer: Ohana Health Plan Medicare	$24.72
Rate for Payer: UnitedHealthcare Medicaid	$29.66
Rate for Payer: UnitedHealthcare Medicaid	$26.23
Rate for Payer: UnitedHealthcare Medicare	$21.86
Rate for Payer: UnitedHealthcare Medicare	$24.72
Rate for Payer: University Health Alliance Commercial	$31.87
Rate for Payer: University Health Alliance Commercial	$36.04

DULoxetine 20 mg capsule [HHSC]

Facility

$49.44

Service Code	HCPCS J8499
Hospital Charge Code	2501062
Hospital Revenue Code	250
Min. Negotiated Rate	$42.02
Max. Negotiated Rate	$47.96
Rate for Payer: Cash Price	$32.14
Rate for Payer: Cash Price	$28.42
Rate for Payer: Health Management Network Commercial	$37.16
Rate for Payer: Health Management Network Commercial	$42.02
Rate for Payer: Kaiser Permanente Commercial	$39.35
Rate for Payer: Kaiser Permanente Commercial	$44.50
Rate for Payer: MDX Hawaii PPO	$47.96
Rate for Payer: MDX Hawaii PPO	$42.41

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001059504
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041404
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041405
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041404
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001059504
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001059505
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 60687073401
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.10
Max. Negotiated Rate	$45.76
Rate for Payer: Cash Price	$30.67
Rate for Payer: Health Management Network Commercial	$40.10
Rate for Payer: Kaiser Permanente Commercial	$42.46
Rate for Payer: MDX Hawaii PPO	$45.76

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041405
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 68084068301
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.59
Max. Negotiated Rate	$45.76
Rate for Payer: AlohaCare Medicaid	$23.59
Rate for Payer: AlohaCare Medicare	$23.59
Rate for Payer: Cash Price	$30.67
Rate for Payer: Devoted Health Medicare	$25.95
Rate for Payer: Hawaii Medical Service Association Medicare	$23.59
Rate for Payer: Hawaii Western Management Group Commercial	$44.82
Rate for Payer: Health Management Network Commercial	$40.10
Rate for Payer: Humana Medicare	$23.59
Rate for Payer: Kaiser Permanente Commercial	$42.46
Rate for Payer: Kaiser Permanente Medicaid	$24.06
Rate for Payer: Kaiser Permanente Medicare	$23.59
Rate for Payer: MDX Hawaii PPO	$45.76
Rate for Payer: Ohana Health Plan Medicaid	$23.59
Rate for Payer: Ohana Health Plan Medicare	$23.59
Rate for Payer: UnitedHealthcare Medicaid	$28.31
Rate for Payer: UnitedHealthcare Medicare	$23.59
Rate for Payer: University Health Alliance Commercial	$34.39

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 60687073401
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.59
Max. Negotiated Rate	$45.76
Rate for Payer: AlohaCare Medicaid	$23.59
Rate for Payer: AlohaCare Medicare	$23.59
Rate for Payer: Cash Price	$30.67
Rate for Payer: Devoted Health Medicare	$25.95
Rate for Payer: Hawaii Medical Service Association Medicare	$23.59
Rate for Payer: Hawaii Western Management Group Commercial	$44.82
Rate for Payer: Health Management Network Commercial	$40.10
Rate for Payer: Humana Medicare	$23.59
Rate for Payer: Kaiser Permanente Commercial	$42.46
Rate for Payer: Kaiser Permanente Medicaid	$24.06
Rate for Payer: Kaiser Permanente Medicare	$23.59
Rate for Payer: MDX Hawaii PPO	$45.76
Rate for Payer: Ohana Health Plan Medicaid	$23.59
Rate for Payer: Ohana Health Plan Medicare	$23.59
Rate for Payer: UnitedHealthcare Medicaid	$28.31
Rate for Payer: UnitedHealthcare Medicare	$23.59
Rate for Payer: University Health Alliance Commercial	$34.39

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001059505
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 68084068301
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.10
Max. Negotiated Rate	$45.76
Rate for Payer: Cash Price	$30.67
Rate for Payer: Health Management Network Commercial	$40.10
Rate for Payer: Kaiser Permanente Commercial	$42.46
Rate for Payer: MDX Hawaii PPO	$45.76

Duovisc Kit

Facility

$582.00

Hospital Charge Code	8527569
Hospital Revenue Code	272
Min. Negotiated Rate	$494.70
Max. Negotiated Rate	$564.54
Rate for Payer: Cash Price	$378.30
Rate for Payer: Health Management Network Commercial	$494.70
Rate for Payer: Kaiser Permanente Commercial	$523.80
Rate for Payer: MDX Hawaii PPO	$564.54

Duovisc Kit

Facility

$582.00

Hospital Charge Code	8527569
Hospital Revenue Code	272
Min. Negotiated Rate	$291.00
Max. Negotiated Rate	$564.54
Rate for Payer: AlohaCare Medicaid	$291.00
Rate for Payer: AlohaCare Medicare	$291.00
Rate for Payer: Cash Price	$378.30
Rate for Payer: Devoted Health Medicare	$320.10
Rate for Payer: Hawaii Medical Service Association Medicare	$291.00
Rate for Payer: Hawaii Western Management Group Commercial	$552.90
Rate for Payer: Health Management Network Commercial	$494.70
Rate for Payer: Humana Medicare	$291.00
Rate for Payer: Kaiser Permanente Commercial	$523.80
Rate for Payer: Kaiser Permanente Medicaid	$296.82
Rate for Payer: Kaiser Permanente Medicare	$291.00
Rate for Payer: MDX Hawaii PPO	$564.54
Rate for Payer: Ohana Health Plan Medicaid	$291.00
Rate for Payer: Ohana Health Plan Medicare	$291.00
Rate for Payer: UnitedHealthcare Medicare	$291.00
Rate for Payer: University Health Alliance Commercial	$424.22

DYSEQUILIBRIUM

Facility

$13,691.35

Service Code	MSDRG 149
Min. Negotiated Rate	$13,691.35
Max. Negotiated Rate	$13,691.35
Rate for Payer: Hawaii Medical Service Association Commercial	$13,691.35

E95705 EEG Tech - Unmonitored 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95705
Hospital Charge Code	12284971
Hospital Revenue Code	740
Min. Negotiated Rate	$233.55
Max. Negotiated Rate	$1,921.57
Rate for Payer: AlohaCare Medicaid	$990.50
Rate for Payer: AlohaCare Medicare	$990.50
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Devoted Health Medicare	$1,089.55
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$990.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,881.95
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Humana Medicare	$990.50
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: Kaiser Permanente Medicaid	$1,010.31
Rate for Payer: Kaiser Permanente Medicare	$990.50
Rate for Payer: MDX Hawaii PPO	$1,921.57
Rate for Payer: Ohana Health Plan Medicaid	$990.50
Rate for Payer: Ohana Health Plan Medicare	$990.50
Rate for Payer: UnitedHealthcare Medicaid	$233.55
Rate for Payer: UnitedHealthcare Medicare	$990.50
Rate for Payer: University Health Alliance Commercial	$1,443.95

E95705 EEG Tech - Unmonitored 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95705
Hospital Charge Code	12284971
Hospital Revenue Code	740
Min. Negotiated Rate	$1,683.85
Max. Negotiated Rate	$1,921.57
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: MDX Hawaii PPO	$1,921.57

E95706 EEG Tech - Intermittent Monitoring and Maintenance 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95706
Hospital Charge Code	12283600
Hospital Revenue Code	740
Min. Negotiated Rate	$1,683.85
Max. Negotiated Rate	$1,921.57
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: MDX Hawaii PPO	$1,921.57

Know your out-of-pocket cost for care.

All Charges