Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

erythromycin 0.5% ophth oint 1gm [HHSC]

Facility

$70.02

Service Code	NDC 24208091019
Hospital Charge Code	2500308
Hospital Revenue Code	250
Min. Negotiated Rate	$35.01
Max. Negotiated Rate	$67.92
Rate for Payer: AlohaCare Medicaid	$35.01
Rate for Payer: AlohaCare Medicare	$35.01
Rate for Payer: Cash Price	$45.51
Rate for Payer: Devoted Health Medicare	$38.51
Rate for Payer: Hawaii Medical Service Association Medicare	$35.01
Rate for Payer: Hawaii Western Management Group Commercial	$66.52
Rate for Payer: Health Management Network Commercial	$59.52
Rate for Payer: Humana Medicare	$35.01
Rate for Payer: Kaiser Permanente Commercial	$63.02
Rate for Payer: Kaiser Permanente Medicaid	$35.71
Rate for Payer: Kaiser Permanente Medicare	$35.01
Rate for Payer: MDX Hawaii PPO	$67.92
Rate for Payer: Ohana Health Plan Medicaid	$35.01
Rate for Payer: Ohana Health Plan Medicare	$35.01
Rate for Payer: UnitedHealthcare Medicaid	$42.01
Rate for Payer: UnitedHealthcare Medicare	$35.01
Rate for Payer: University Health Alliance Commercial	$51.04

erythromycin 0.5% ophth oint 1gm [HHSC]

Facility

$101.90

Service Code	NDC 72485067031
Hospital Charge Code	2500308
Hospital Revenue Code	250
Min. Negotiated Rate	$50.95
Max. Negotiated Rate	$98.84
Rate for Payer: AlohaCare Medicaid	$50.95
Rate for Payer: AlohaCare Medicare	$50.95
Rate for Payer: Cash Price	$66.24
Rate for Payer: Devoted Health Medicare	$56.05
Rate for Payer: Hawaii Medical Service Association Medicare	$50.95
Rate for Payer: Hawaii Western Management Group Commercial	$96.81
Rate for Payer: Health Management Network Commercial	$86.61
Rate for Payer: Humana Medicare	$50.95
Rate for Payer: Kaiser Permanente Commercial	$91.71
Rate for Payer: Kaiser Permanente Medicaid	$51.97
Rate for Payer: Kaiser Permanente Medicare	$50.95
Rate for Payer: MDX Hawaii PPO	$98.84
Rate for Payer: Ohana Health Plan Medicaid	$50.95
Rate for Payer: Ohana Health Plan Medicare	$50.95
Rate for Payer: UnitedHealthcare Medicaid	$61.14
Rate for Payer: UnitedHealthcare Medicare	$50.95
Rate for Payer: University Health Alliance Commercial	$74.27

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$96.36

Service Code	NDC 00574402435
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$48.18
Max. Negotiated Rate	$93.47
Rate for Payer: AlohaCare Medicaid	$48.18
Rate for Payer: AlohaCare Medicare	$48.18
Rate for Payer: Cash Price	$62.63
Rate for Payer: Devoted Health Medicare	$53.00
Rate for Payer: Hawaii Medical Service Association Medicare	$48.18
Rate for Payer: Hawaii Western Management Group Commercial	$91.54
Rate for Payer: Health Management Network Commercial	$81.91
Rate for Payer: Humana Medicare	$48.18
Rate for Payer: Kaiser Permanente Commercial	$86.72
Rate for Payer: Kaiser Permanente Medicaid	$49.14
Rate for Payer: Kaiser Permanente Medicare	$48.18
Rate for Payer: MDX Hawaii PPO	$93.47
Rate for Payer: Ohana Health Plan Medicaid	$48.18
Rate for Payer: Ohana Health Plan Medicare	$48.18
Rate for Payer: UnitedHealthcare Medicaid	$57.82
Rate for Payer: UnitedHealthcare Medicare	$48.18
Rate for Payer: University Health Alliance Commercial	$70.24

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$139.16

Service Code	NDC 72485067035
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$69.58
Max. Negotiated Rate	$134.99
Rate for Payer: AlohaCare Medicaid	$69.58
Rate for Payer: AlohaCare Medicare	$69.58
Rate for Payer: Cash Price	$90.45
Rate for Payer: Devoted Health Medicare	$76.54
Rate for Payer: Hawaii Medical Service Association Medicare	$69.58
Rate for Payer: Hawaii Western Management Group Commercial	$132.20
Rate for Payer: Health Management Network Commercial	$118.29
Rate for Payer: Humana Medicare	$69.58
Rate for Payer: Kaiser Permanente Commercial	$125.24
Rate for Payer: Kaiser Permanente Medicaid	$70.97
Rate for Payer: Kaiser Permanente Medicare	$69.58
Rate for Payer: MDX Hawaii PPO	$134.99
Rate for Payer: Ohana Health Plan Medicaid	$69.58
Rate for Payer: Ohana Health Plan Medicare	$69.58
Rate for Payer: UnitedHealthcare Medicaid	$83.50
Rate for Payer: UnitedHealthcare Medicare	$69.58
Rate for Payer: University Health Alliance Commercial	$101.43

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$139.16

Service Code	NDC 72485067035
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$118.29
Max. Negotiated Rate	$134.99
Rate for Payer: Cash Price	$90.45
Rate for Payer: Health Management Network Commercial	$118.29
Rate for Payer: Kaiser Permanente Commercial	$125.24
Rate for Payer: MDX Hawaii PPO	$134.99

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$96.11

Service Code	NDC 17478007035
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$93.23
Rate for Payer: AlohaCare Medicaid	$48.05
Rate for Payer: AlohaCare Medicare	$48.05
Rate for Payer: Cash Price	$62.47
Rate for Payer: Devoted Health Medicare	$52.86
Rate for Payer: Hawaii Medical Service Association Medicare	$48.05
Rate for Payer: Hawaii Western Management Group Commercial	$91.30
Rate for Payer: Health Management Network Commercial	$81.69
Rate for Payer: Humana Medicare	$48.05
Rate for Payer: Kaiser Permanente Commercial	$86.50
Rate for Payer: Kaiser Permanente Medicaid	$49.02
Rate for Payer: Kaiser Permanente Medicare	$48.05
Rate for Payer: MDX Hawaii PPO	$93.23
Rate for Payer: Ohana Health Plan Medicaid	$48.05
Rate for Payer: Ohana Health Plan Medicare	$48.05
Rate for Payer: UnitedHealthcare Medicaid	$57.67
Rate for Payer: UnitedHealthcare Medicare	$48.05
Rate for Payer: University Health Alliance Commercial	$70.05

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$96.11

Service Code	NDC 17478007035
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$81.69
Max. Negotiated Rate	$93.23
Rate for Payer: Cash Price	$62.47
Rate for Payer: Health Management Network Commercial	$81.69
Rate for Payer: Kaiser Permanente Commercial	$86.50
Rate for Payer: MDX Hawaii PPO	$93.23

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$97.57

Service Code	NDC 24208091055
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$48.78
Max. Negotiated Rate	$94.64
Rate for Payer: AlohaCare Medicaid	$48.78
Rate for Payer: AlohaCare Medicare	$48.78
Rate for Payer: Cash Price	$63.42
Rate for Payer: Devoted Health Medicare	$53.66
Rate for Payer: Hawaii Medical Service Association Medicare	$48.78
Rate for Payer: Hawaii Western Management Group Commercial	$92.69
Rate for Payer: Health Management Network Commercial	$82.93
Rate for Payer: Humana Medicare	$48.78
Rate for Payer: Kaiser Permanente Commercial	$87.81
Rate for Payer: Kaiser Permanente Medicaid	$49.76
Rate for Payer: Kaiser Permanente Medicare	$48.78
Rate for Payer: MDX Hawaii PPO	$94.64
Rate for Payer: Ohana Health Plan Medicaid	$48.78
Rate for Payer: Ohana Health Plan Medicare	$48.78
Rate for Payer: UnitedHealthcare Medicaid	$58.54
Rate for Payer: UnitedHealthcare Medicare	$48.78
Rate for Payer: University Health Alliance Commercial	$71.12

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$96.36

Service Code	NDC 00574402435
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$81.91
Max. Negotiated Rate	$93.47
Rate for Payer: Cash Price	$62.63
Rate for Payer: Health Management Network Commercial	$81.91
Rate for Payer: Kaiser Permanente Commercial	$86.72
Rate for Payer: MDX Hawaii PPO	$93.47

erythromycin 0.5% ophth oint 3.5gm [HHSC]

Facility

$97.57

Service Code	NDC 24208091055
Hospital Charge Code	2500309
Hospital Revenue Code	250
Min. Negotiated Rate	$82.93
Max. Negotiated Rate	$94.64
Rate for Payer: Cash Price	$63.42
Rate for Payer: Health Management Network Commercial	$82.93
Rate for Payer: Kaiser Permanente Commercial	$87.81
Rate for Payer: MDX Hawaii PPO	$94.64

Erythropoietin (EPO) FSI

Facility

$109.00

Service Code	HCPCS 82668
Hospital Charge Code	8404557
Hospital Revenue Code	301
Min. Negotiated Rate	$18.79
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$54.50
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Devoted Health Medicare	$59.95
Rate for Payer: Hawaii Medical Service Association ABD	$25.97
Rate for Payer: Hawaii Medical Service Association Commercial	$23.49
Rate for Payer: Hawaii Medical Service Association Medicare	$54.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.27
Rate for Payer: Hawaii Western Management Group Commercial	$18.79
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$54.50
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$54.50
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$54.50
Rate for Payer: Ohana Health Plan Medicare	$54.50
Rate for Payer: UnitedHealthcare Medicaid	$25.97
Rate for Payer: UnitedHealthcare Medicare	$54.50
Rate for Payer: University Health Alliance Commercial	$48.58

Erythropoietin (EPO) FSI

Facility

$109.00

Service Code	HCPCS 82668
Hospital Charge Code	8404557
Hospital Revenue Code	301
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

escitalopram 10 mg tablet [HHSC]

Facility

$24.02

Service Code	NDC 68084061701
Hospital Charge Code	2500310
Hospital Revenue Code	250
Min. Negotiated Rate	$12.01
Max. Negotiated Rate	$23.30
Rate for Payer: AlohaCare Medicaid	$12.01
Rate for Payer: AlohaCare Medicare	$12.01
Rate for Payer: Cash Price	$15.61
Rate for Payer: Devoted Health Medicare	$13.21
Rate for Payer: Hawaii Medical Service Association Medicare	$12.01
Rate for Payer: Hawaii Western Management Group Commercial	$22.82
Rate for Payer: Health Management Network Commercial	$20.42
Rate for Payer: Humana Medicare	$12.01
Rate for Payer: Kaiser Permanente Commercial	$21.62
Rate for Payer: Kaiser Permanente Medicaid	$12.25
Rate for Payer: Kaiser Permanente Medicare	$12.01
Rate for Payer: MDX Hawaii PPO	$23.30
Rate for Payer: Ohana Health Plan Medicaid	$12.01
Rate for Payer: Ohana Health Plan Medicare	$12.01
Rate for Payer: UnitedHealthcare Medicaid	$14.41
Rate for Payer: UnitedHealthcare Medicare	$12.01
Rate for Payer: University Health Alliance Commercial	$17.51

escitalopram 10 mg tablet [HHSC]

Facility

$24.36

Service Code	NDC 00904642661
Hospital Charge Code	2500310
Hospital Revenue Code	250
Min. Negotiated Rate	$12.18
Max. Negotiated Rate	$23.63
Rate for Payer: AlohaCare Medicaid	$12.18
Rate for Payer: AlohaCare Medicare	$12.18
Rate for Payer: Cash Price	$15.83
Rate for Payer: Devoted Health Medicare	$13.40
Rate for Payer: Hawaii Medical Service Association Medicare	$12.18
Rate for Payer: Hawaii Western Management Group Commercial	$23.14
Rate for Payer: Health Management Network Commercial	$20.71
Rate for Payer: Humana Medicare	$12.18
Rate for Payer: Kaiser Permanente Commercial	$21.92
Rate for Payer: Kaiser Permanente Medicaid	$12.42
Rate for Payer: Kaiser Permanente Medicare	$12.18
Rate for Payer: MDX Hawaii PPO	$23.63
Rate for Payer: Ohana Health Plan Medicaid	$12.18
Rate for Payer: Ohana Health Plan Medicare	$12.18
Rate for Payer: UnitedHealthcare Medicaid	$14.62
Rate for Payer: UnitedHealthcare Medicare	$12.18
Rate for Payer: University Health Alliance Commercial	$17.76

escitalopram 10 mg tablet [HHSC]

Facility

$24.02

Service Code	NDC 68084061701
Hospital Charge Code	2500310
Hospital Revenue Code	250
Min. Negotiated Rate	$20.42
Max. Negotiated Rate	$23.30
Rate for Payer: Cash Price	$15.61
Rate for Payer: Health Management Network Commercial	$20.42
Rate for Payer: Kaiser Permanente Commercial	$21.62
Rate for Payer: MDX Hawaii PPO	$23.30

escitalopram 10 mg tablet [HHSC]

Facility

$24.36

Service Code	NDC 00904642661
Hospital Charge Code	2500310
Hospital Revenue Code	250
Min. Negotiated Rate	$20.71
Max. Negotiated Rate	$23.63
Rate for Payer: Cash Price	$15.83
Rate for Payer: Health Management Network Commercial	$20.71
Rate for Payer: Kaiser Permanente Commercial	$21.92
Rate for Payer: MDX Hawaii PPO	$23.63

esmolol 100 mg/10mL vial [HHSC]

Facility

$52.29

Service Code	NDC 67457018210
Hospital Charge Code	2500312
Hospital Revenue Code	250
Min. Negotiated Rate	$44.45
Max. Negotiated Rate	$50.72
Rate for Payer: Cash Price	$33.99
Rate for Payer: Health Management Network Commercial	$44.45
Rate for Payer: Kaiser Permanente Commercial	$47.06
Rate for Payer: MDX Hawaii PPO	$50.72

esmolol 100 mg/10mL vial [HHSC]

Facility

$52.54

Service Code	NDC 55150019410
Hospital Charge Code	2500312
Hospital Revenue Code	250
Min. Negotiated Rate	$44.66
Max. Negotiated Rate	$50.96
Rate for Payer: Cash Price	$34.15
Rate for Payer: Health Management Network Commercial	$44.66
Rate for Payer: Kaiser Permanente Commercial	$47.29
Rate for Payer: MDX Hawaii PPO	$50.96

esmolol 100 mg/10mL vial [HHSC]

Facility

$90.28

Service Code	NDC 63323065210
Hospital Charge Code	2500312
Hospital Revenue Code	250
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$87.57
Rate for Payer: AlohaCare Medicaid	$45.14
Rate for Payer: AlohaCare Medicare	$45.14
Rate for Payer: Cash Price	$58.68
Rate for Payer: Devoted Health Medicare	$49.65
Rate for Payer: Hawaii Medical Service Association Medicare	$45.14
Rate for Payer: Hawaii Western Management Group Commercial	$85.77
Rate for Payer: Health Management Network Commercial	$76.74
Rate for Payer: Humana Medicare	$45.14
Rate for Payer: Kaiser Permanente Commercial	$81.25
Rate for Payer: Kaiser Permanente Medicaid	$46.04
Rate for Payer: Kaiser Permanente Medicare	$45.14
Rate for Payer: MDX Hawaii PPO	$87.57
Rate for Payer: Ohana Health Plan Medicaid	$45.14
Rate for Payer: Ohana Health Plan Medicare	$45.14
Rate for Payer: UnitedHealthcare Medicaid	$54.17
Rate for Payer: UnitedHealthcare Medicare	$45.14
Rate for Payer: University Health Alliance Commercial	$65.81

esmolol 100 mg/10mL vial [HHSC]

Facility

$52.29

Service Code	NDC 67457018210
Hospital Charge Code	2500312
Hospital Revenue Code	250
Min. Negotiated Rate	$26.14
Max. Negotiated Rate	$50.72
Rate for Payer: AlohaCare Medicaid	$26.14
Rate for Payer: AlohaCare Medicare	$26.14
Rate for Payer: Cash Price	$33.99
Rate for Payer: Devoted Health Medicare	$28.76
Rate for Payer: Hawaii Medical Service Association Medicare	$26.14
Rate for Payer: Hawaii Western Management Group Commercial	$49.68
Rate for Payer: Health Management Network Commercial	$44.45
Rate for Payer: Humana Medicare	$26.14
Rate for Payer: Kaiser Permanente Commercial	$47.06
Rate for Payer: Kaiser Permanente Medicaid	$26.67
Rate for Payer: Kaiser Permanente Medicare	$26.14
Rate for Payer: MDX Hawaii PPO	$50.72
Rate for Payer: Ohana Health Plan Medicaid	$26.14
Rate for Payer: Ohana Health Plan Medicare	$26.14
Rate for Payer: UnitedHealthcare Medicaid	$31.37
Rate for Payer: UnitedHealthcare Medicare	$26.14
Rate for Payer: University Health Alliance Commercial	$38.11

esmolol 100 mg/10mL vial [HHSC]

Facility

$90.28

Service Code	NDC 63323065210
Hospital Charge Code	2500312
Hospital Revenue Code	250
Min. Negotiated Rate	$76.74
Max. Negotiated Rate	$87.57
Rate for Payer: Cash Price	$58.68
Rate for Payer: Health Management Network Commercial	$76.74
Rate for Payer: Kaiser Permanente Commercial	$81.25
Rate for Payer: MDX Hawaii PPO	$87.57

esmolol 100 mg/10mL vial [HHSC]

Facility

$52.54

Service Code	NDC 55150019410
Hospital Charge Code	2500312
Hospital Revenue Code	250
Min. Negotiated Rate	$26.27
Max. Negotiated Rate	$50.96
Rate for Payer: AlohaCare Medicaid	$26.27
Rate for Payer: AlohaCare Medicare	$26.27
Rate for Payer: Cash Price	$34.15
Rate for Payer: Devoted Health Medicare	$28.90
Rate for Payer: Hawaii Medical Service Association Medicare	$26.27
Rate for Payer: Hawaii Western Management Group Commercial	$49.91
Rate for Payer: Health Management Network Commercial	$44.66
Rate for Payer: Humana Medicare	$26.27
Rate for Payer: Kaiser Permanente Commercial	$47.29
Rate for Payer: Kaiser Permanente Medicaid	$26.80
Rate for Payer: Kaiser Permanente Medicare	$26.27
Rate for Payer: MDX Hawaii PPO	$50.96
Rate for Payer: Ohana Health Plan Medicaid	$26.27
Rate for Payer: Ohana Health Plan Medicare	$26.27
Rate for Payer: UnitedHealthcare Medicaid	$31.52
Rate for Payer: UnitedHealthcare Medicare	$26.27
Rate for Payer: University Health Alliance Commercial	$38.30

esmolol-ns 2500 mg/250ml premix [HHSC]

Facility

$1,414.93

Service Code	NDC 10019005561
Hospital Charge Code	2500313
Hospital Revenue Code	250
Min. Negotiated Rate	$707.47
Max. Negotiated Rate	$1,372.48
Rate for Payer: AlohaCare Medicaid	$707.47
Rate for Payer: AlohaCare Medicare	$707.47
Rate for Payer: Cash Price	$919.70
Rate for Payer: Devoted Health Medicare	$778.21
Rate for Payer: Hawaii Medical Service Association Medicare	$707.47
Rate for Payer: Hawaii Western Management Group Commercial	$1,344.18
Rate for Payer: Health Management Network Commercial	$1,202.69
Rate for Payer: Humana Medicare	$707.47
Rate for Payer: Kaiser Permanente Commercial	$1,273.44
Rate for Payer: Kaiser Permanente Medicaid	$721.61
Rate for Payer: Kaiser Permanente Medicare	$707.47
Rate for Payer: MDX Hawaii PPO	$1,372.48
Rate for Payer: Ohana Health Plan Medicaid	$707.47
Rate for Payer: Ohana Health Plan Medicare	$707.47
Rate for Payer: UnitedHealthcare Medicaid	$848.96
Rate for Payer: UnitedHealthcare Medicare	$707.47
Rate for Payer: University Health Alliance Commercial	$1,031.34

esmolol-ns 2500 mg/250ml premix [HHSC]

Facility

$1,414.93

Service Code	NDC 10019005561
Hospital Charge Code	2500313
Hospital Revenue Code	250
Min. Negotiated Rate	$1,202.69
Max. Negotiated Rate	$1,372.48
Rate for Payer: Cash Price	$919.70
Rate for Payer: Health Management Network Commercial	$1,202.69
Rate for Payer: Kaiser Permanente Commercial	$1,273.44
Rate for Payer: MDX Hawaii PPO	$1,372.48

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$18,204.14

Service Code	MSDRG 391
Min. Negotiated Rate	$18,204.14
Max. Negotiated Rate	$18,204.14
Rate for Payer: Hawaii Medical Service Association Commercial	$18,204.14

Know your out-of-pocket cost for care.

All Charges