Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$128.33

Service Code	NDC 00378912298
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$64.17
Max. Negotiated Rate	$124.48
Rate for Payer: AlohaCare Medicaid	$64.17
Rate for Payer: AlohaCare Medicare	$64.17
Rate for Payer: Cash Price	$83.41
Rate for Payer: Devoted Health Medicare	$70.58
Rate for Payer: Hawaii Medical Service Association Medicare	$64.17
Rate for Payer: Hawaii Western Management Group Commercial	$121.91
Rate for Payer: Health Management Network Commercial	$109.08
Rate for Payer: Humana Medicare	$64.17
Rate for Payer: Kaiser Permanente Commercial	$115.50
Rate for Payer: Kaiser Permanente Medicaid	$65.45
Rate for Payer: Kaiser Permanente Medicare	$64.17
Rate for Payer: MDX Hawaii PPO	$124.48
Rate for Payer: Ohana Health Plan Medicaid	$64.17
Rate for Payer: Ohana Health Plan Medicare	$64.17
Rate for Payer: UnitedHealthcare Medicaid	$77.00
Rate for Payer: UnitedHealthcare Medicare	$64.17
Rate for Payer: University Health Alliance Commercial	$93.54

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$180.68

Service Code	NDC 60505700702
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$153.58
Max. Negotiated Rate	$175.26
Rate for Payer: Cash Price	$117.44
Rate for Payer: Health Management Network Commercial	$153.58
Rate for Payer: Kaiser Permanente Commercial	$162.61
Rate for Payer: MDX Hawaii PPO	$175.26

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$128.33

Service Code	NDC 00378912298
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$109.08
Max. Negotiated Rate	$124.48
Rate for Payer: Cash Price	$83.41
Rate for Payer: Health Management Network Commercial	$109.08
Rate for Payer: Kaiser Permanente Commercial	$115.50
Rate for Payer: MDX Hawaii PPO	$124.48

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$180.68

Service Code	NDC 60505700702
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$90.34
Max. Negotiated Rate	$175.26
Rate for Payer: AlohaCare Medicaid	$90.34
Rate for Payer: AlohaCare Medicare	$90.34
Rate for Payer: Cash Price	$117.44
Rate for Payer: Devoted Health Medicare	$99.37
Rate for Payer: Hawaii Medical Service Association Medicare	$90.34
Rate for Payer: Hawaii Western Management Group Commercial	$171.65
Rate for Payer: Health Management Network Commercial	$153.58
Rate for Payer: Humana Medicare	$90.34
Rate for Payer: Kaiser Permanente Commercial	$162.61
Rate for Payer: Kaiser Permanente Medicaid	$92.15
Rate for Payer: Kaiser Permanente Medicare	$90.34
Rate for Payer: MDX Hawaii PPO	$175.26
Rate for Payer: Ohana Health Plan Medicaid	$90.34
Rate for Payer: Ohana Health Plan Medicare	$90.34
Rate for Payer: UnitedHealthcare Medicaid	$108.41
Rate for Payer: UnitedHealthcare Medicare	$90.34
Rate for Payer: University Health Alliance Commercial	$131.70

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$128.33

Service Code	NDC 00406915076
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$64.17
Max. Negotiated Rate	$124.48
Rate for Payer: AlohaCare Medicaid	$64.17
Rate for Payer: AlohaCare Medicare	$64.17
Rate for Payer: Cash Price	$83.41
Rate for Payer: Devoted Health Medicare	$70.58
Rate for Payer: Hawaii Medical Service Association Medicare	$64.17
Rate for Payer: Hawaii Western Management Group Commercial	$121.91
Rate for Payer: Health Management Network Commercial	$109.08
Rate for Payer: Humana Medicare	$64.17
Rate for Payer: Kaiser Permanente Commercial	$115.50
Rate for Payer: Kaiser Permanente Medicaid	$65.45
Rate for Payer: Kaiser Permanente Medicare	$64.17
Rate for Payer: MDX Hawaii PPO	$124.48
Rate for Payer: Ohana Health Plan Medicaid	$64.17
Rate for Payer: Ohana Health Plan Medicare	$64.17
Rate for Payer: UnitedHealthcare Medicaid	$77.00
Rate for Payer: UnitedHealthcare Medicare	$64.17
Rate for Payer: University Health Alliance Commercial	$93.54

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$128.33

Service Code	NDC 00406915076
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$109.08
Max. Negotiated Rate	$124.48
Rate for Payer: Cash Price	$83.41
Rate for Payer: Health Management Network Commercial	$109.08
Rate for Payer: Kaiser Permanente Commercial	$115.50
Rate for Payer: MDX Hawaii PPO	$124.48

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$128.33

Service Code	NDC 00406905076
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$64.17
Max. Negotiated Rate	$124.48
Rate for Payer: AlohaCare Medicaid	$64.17
Rate for Payer: AlohaCare Medicare	$64.17
Rate for Payer: Cash Price	$83.41
Rate for Payer: Devoted Health Medicare	$70.58
Rate for Payer: Hawaii Medical Service Association Medicare	$64.17
Rate for Payer: Hawaii Western Management Group Commercial	$121.91
Rate for Payer: Health Management Network Commercial	$109.08
Rate for Payer: Humana Medicare	$64.17
Rate for Payer: Kaiser Permanente Commercial	$115.50
Rate for Payer: Kaiser Permanente Medicaid	$65.45
Rate for Payer: Kaiser Permanente Medicare	$64.17
Rate for Payer: MDX Hawaii PPO	$124.48
Rate for Payer: Ohana Health Plan Medicaid	$64.17
Rate for Payer: Ohana Health Plan Medicare	$64.17
Rate for Payer: UnitedHealthcare Medicaid	$77.00
Rate for Payer: UnitedHealthcare Medicare	$64.17
Rate for Payer: University Health Alliance Commercial	$93.54

fentaNYL 50 mcg/hr patch [HHSC]

Facility

$128.33

Service Code	NDC 00406905076
Hospital Charge Code	2500323
Hospital Revenue Code	250
Min. Negotiated Rate	$109.08
Max. Negotiated Rate	$124.48
Rate for Payer: Cash Price	$83.41
Rate for Payer: Health Management Network Commercial	$109.08
Rate for Payer: Kaiser Permanente Commercial	$115.50
Rate for Payer: MDX Hawaii PPO	$124.48

fentaNYL-NS 1250 mcg/25 mL premix [HHSC]

Facility

$183.85

Service Code	HCPCS J3010
Hospital Charge Code	2501136
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$178.33
Rate for Payer: AlohaCare Medicaid	$91.92
Rate for Payer: AlohaCare Medicare	$91.92
Rate for Payer: Cash Price	$119.50
Rate for Payer: Cash Price	$119.50
Rate for Payer: Devoted Health Medicare	$101.12
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Medicare	$91.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Western Management Group Commercial	$174.66
Rate for Payer: Health Management Network Commercial	$156.27
Rate for Payer: Humana Medicare	$91.92
Rate for Payer: Kaiser Permanente Commercial	$165.47
Rate for Payer: Kaiser Permanente Medicaid	$93.76
Rate for Payer: Kaiser Permanente Medicare	$91.92
Rate for Payer: MDX Hawaii PPO	$178.33
Rate for Payer: Ohana Health Plan Medicaid	$91.92
Rate for Payer: Ohana Health Plan Medicare	$91.92
Rate for Payer: UnitedHealthcare Medicaid	$110.31
Rate for Payer: UnitedHealthcare Medicare	$91.92
Rate for Payer: University Health Alliance Commercial	$134.01

fentaNYL-NS 1250 mcg/25 mL premix [HHSC]

Facility

$183.85

Service Code	HCPCS J3010
Hospital Charge Code	2501136
Hospital Revenue Code	250
Min. Negotiated Rate	$156.27
Max. Negotiated Rate	$178.33
Rate for Payer: Cash Price	$119.50
Rate for Payer: Health Management Network Commercial	$156.27
Rate for Payer: Kaiser Permanente Commercial	$165.47
Rate for Payer: MDX Hawaii PPO	$178.33

Fentanyl Quant Urine FSI

Facility

$300.00

Service Code	HCPCS 80354
Hospital Charge Code	8686247
Hospital Revenue Code	300
Min. Negotiated Rate	$26.89
Max. Negotiated Rate	$291.00
Rate for Payer: AlohaCare Medicaid	$150.00
Rate for Payer: AlohaCare Medicare	$150.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Hawaii Medical Service Association ABD	$26.89
Rate for Payer: Hawaii Medical Service Association Medicare	$150.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.23
Rate for Payer: Hawaii Western Management Group Commercial	$285.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Humana Medicare	$150.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: Kaiser Permanente Medicaid	$153.00
Rate for Payer: Kaiser Permanente Medicare	$150.00
Rate for Payer: MDX Hawaii PPO	$291.00
Rate for Payer: Ohana Health Plan Medicaid	$150.00
Rate for Payer: Ohana Health Plan Medicare	$150.00
Rate for Payer: UnitedHealthcare Medicare	$150.00
Rate for Payer: University Health Alliance Commercial	$218.67

Fentanyl Quant Urine FSI

Facility

$300.00

Service Code	HCPCS 80354
Hospital Charge Code	8686247
Hospital Revenue Code	300
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

Ferritin FSI

Facility

$123.00

Service Code	HCPCS 82728
Hospital Charge Code	8117909
Hospital Revenue Code	301
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$119.31
Rate for Payer: Cash Price	$79.95
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Kaiser Permanente Commercial	$110.70
Rate for Payer: MDX Hawaii PPO	$119.31

Ferritin FSI

Facility

$123.00

Service Code	HCPCS 82728
Hospital Charge Code	8117909
Hospital Revenue Code	301
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$119.31
Rate for Payer: AlohaCare Medicaid	$61.50
Rate for Payer: AlohaCare Medicare	$61.50
Rate for Payer: Cash Price	$79.95
Rate for Payer: Cash Price	$79.95
Rate for Payer: Devoted Health Medicare	$67.65
Rate for Payer: Hawaii Medical Service Association ABD	$15.81
Rate for Payer: Hawaii Medical Service Association Commercial	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$61.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.60
Rate for Payer: Hawaii Western Management Group Commercial	$13.63
Rate for Payer: Health Management Network Commercial	$104.55
Rate for Payer: Humana Medicare	$61.50
Rate for Payer: Kaiser Permanente Commercial	$110.70
Rate for Payer: Kaiser Permanente Medicaid	$62.73
Rate for Payer: Kaiser Permanente Medicare	$61.50
Rate for Payer: MDX Hawaii PPO	$119.31
Rate for Payer: Ohana Health Plan Medicaid	$61.50
Rate for Payer: Ohana Health Plan Medicare	$61.50
Rate for Payer: UnitedHealthcare Medicaid	$15.81
Rate for Payer: UnitedHealthcare Medicare	$61.50
Rate for Payer: University Health Alliance Commercial	$29.56

ferrous sulfate 220 mg/5 mL elixir 60 mL [HHSC]

Facility

$6.08

Service Code	NDC 50383077816
Hospital Charge Code	2500971
Hospital Revenue Code	250
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$5.90
Rate for Payer: AlohaCare Medicaid	$3.04
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$3.95
Rate for Payer: Devoted Health Medicare	$3.34
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$5.17
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$5.47
Rate for Payer: Kaiser Permanente Medicaid	$3.10
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$5.90
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicaid	$3.65
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$4.43

ferrous sulfate 220 mg/5 mL elixir 60 mL [HHSC]

Facility

$12.13

Service Code	NDC 54838000180
Hospital Charge Code	2500971
Hospital Revenue Code	250
Min. Negotiated Rate	$6.07
Max. Negotiated Rate	$11.77
Rate for Payer: AlohaCare Medicaid	$6.07
Rate for Payer: AlohaCare Medicare	$6.07
Rate for Payer: Cash Price	$7.88
Rate for Payer: Devoted Health Medicare	$6.67
Rate for Payer: Hawaii Medical Service Association Medicare	$6.07
Rate for Payer: Hawaii Western Management Group Commercial	$11.52
Rate for Payer: Health Management Network Commercial	$10.31
Rate for Payer: Humana Medicare	$6.07
Rate for Payer: Kaiser Permanente Commercial	$10.92
Rate for Payer: Kaiser Permanente Medicaid	$6.19
Rate for Payer: Kaiser Permanente Medicare	$6.07
Rate for Payer: MDX Hawaii PPO	$11.77
Rate for Payer: Ohana Health Plan Medicaid	$6.07
Rate for Payer: Ohana Health Plan Medicare	$6.07
Rate for Payer: UnitedHealthcare Medicaid	$7.28
Rate for Payer: UnitedHealthcare Medicare	$6.07
Rate for Payer: University Health Alliance Commercial	$8.84

ferrous sulfate 220 mg/5 mL elixir 60 mL [HHSC]

Facility

$3.12

Service Code	NDC 57896070916
Hospital Charge Code	2500971
Hospital Revenue Code	250
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$3.03
Rate for Payer: AlohaCare Medicaid	$1.56
Rate for Payer: AlohaCare Medicare	$1.56
Rate for Payer: Cash Price	$2.03
Rate for Payer: Devoted Health Medicare	$1.72
Rate for Payer: Hawaii Medical Service Association Medicare	$1.56
Rate for Payer: Hawaii Western Management Group Commercial	$2.96
Rate for Payer: Health Management Network Commercial	$2.65
Rate for Payer: Humana Medicare	$1.56
Rate for Payer: Kaiser Permanente Commercial	$2.81
Rate for Payer: Kaiser Permanente Medicaid	$1.59
Rate for Payer: Kaiser Permanente Medicare	$1.56
Rate for Payer: MDX Hawaii PPO	$3.03
Rate for Payer: Ohana Health Plan Medicaid	$1.56
Rate for Payer: Ohana Health Plan Medicare	$1.56
Rate for Payer: UnitedHealthcare Medicaid	$1.87
Rate for Payer: UnitedHealthcare Medicare	$1.56
Rate for Payer: University Health Alliance Commercial	$2.27

ferrous sulfate 220 mg/5 mL elixir 60 mL [HHSC]

Facility

$6.08

Service Code	NDC 50383077816
Hospital Charge Code	2500971
Hospital Revenue Code	250
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$5.90
Rate for Payer: Cash Price	$3.95
Rate for Payer: Health Management Network Commercial	$5.17
Rate for Payer: Kaiser Permanente Commercial	$5.47
Rate for Payer: MDX Hawaii PPO	$5.90

ferrous sulfate 220 mg/5 mL elixir 60 mL [HHSC]

Facility

$12.13

Service Code	NDC 54838000180
Hospital Charge Code	2500971
Hospital Revenue Code	250
Min. Negotiated Rate	$10.31
Max. Negotiated Rate	$11.77
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Management Network Commercial	$10.31
Rate for Payer: Kaiser Permanente Commercial	$10.92
Rate for Payer: MDX Hawaii PPO	$11.77

ferrous sulfate 220 mg/5 mL elixir 60 mL [HHSC]

Facility

$3.12

Service Code	NDC 57896070916
Hospital Charge Code	2500971
Hospital Revenue Code	250
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$3.03
Rate for Payer: Cash Price	$2.03
Rate for Payer: Health Management Network Commercial	$2.65
Rate for Payer: Kaiser Permanente Commercial	$2.81
Rate for Payer: MDX Hawaii PPO	$3.03

ferrous sulfate 324 mg EC tablet [HHSC]

Facility

$3.00

Service Code	NDC 00574060811
Hospital Charge Code	2500324
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

ferrous sulfate 324 mg EC tablet [HHSC]

Facility

$3.00

Service Code	NDC 00574060811
Hospital Charge Code	2500324
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

Fetal biophysical profile, without non-stress test

Professional

Both

$172.00

Service Code	HCPCS 76819
Hospital Charge Code	8102222
Hospital Revenue Code	972
Min. Negotiated Rate	$56.22
Max. Negotiated Rate	$146.20
Rate for Payer: AlohaCare Medicaid	$56.22
Rate for Payer: AlohaCare Medicare	$95.33
Rate for Payer: Cash Price	$111.80
Rate for Payer: Cash Price	$111.80
Rate for Payer: Devoted Health Medicare	$104.86
Rate for Payer: Hawaii Medical Service Association Medicare	$95.33
Rate for Payer: Hawaii Western Management Group Commercial	$109.03
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Kaiser Permanente Commercial	$104.86
Rate for Payer: Kaiser Permanente Medicaid	$104.86
Rate for Payer: Kaiser Permanente Medicare	$104.86
Rate for Payer: Ohana Health Plan Medicaid	$56.22
Rate for Payer: Ohana Health Plan Medicare	$95.33
Rate for Payer: UnitedHealthcare Medicaid	$56.22
Rate for Payer: UnitedHealthcare Medicare	$95.33

Fetal biophysical profile, without non-stress test

Facility

$145.00

Service Code	HCPCS 76819
Hospital Charge Code	8102222
Hospital Revenue Code	972
Min. Negotiated Rate	$46.56
Max. Negotiated Rate	$195.62
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	$46.56
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.13
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
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	$46.56
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$195.62

Fetal biophysical profile, without non-stress test

Facility

$145.00

Service Code	HCPCS 76819
Hospital Charge Code	8102222
Hospital Revenue Code	972
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

Know your out-of-pocket cost for care.

All Charges