Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHY RADIOLOGIC SUPERVISION AND INTERPRETATION, AND RADIOGRAPHIC DOCUMENTATION OF FINAL CATHETER POSITION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 77001
Hospital Revenue Code	360
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$2,837.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.86
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$5.23
Rate for Payer: University Health Alliance Commercial	$195.54

fluticasone 50mcg/spray 16gm nasal [HHSC]

Facility

$397.13

Service Code	NDC 60505082901
Hospital Charge Code	2500339
Hospital Revenue Code	250
Min. Negotiated Rate	$337.56
Max. Negotiated Rate	$385.22
Rate for Payer: Cash Price	$258.13
Rate for Payer: Health Management Network Commercial	$337.56
Rate for Payer: Kaiser Permanente Commercial	$357.42
Rate for Payer: MDX Hawaii PPO	$385.22

fluticasone 50mcg/spray 16gm nasal [HHSC]

Facility

$362.37

Service Code	NDC 00054327099
Hospital Charge Code	2500339
Hospital Revenue Code	250
Min. Negotiated Rate	$181.19
Max. Negotiated Rate	$351.50
Rate for Payer: AlohaCare Medicaid	$181.19
Rate for Payer: AlohaCare Medicare	$181.19
Rate for Payer: Cash Price	$235.54
Rate for Payer: Devoted Health Medicare	$199.30
Rate for Payer: Hawaii Medical Service Association Medicare	$181.19
Rate for Payer: Hawaii Western Management Group Commercial	$344.25
Rate for Payer: Health Management Network Commercial	$308.01
Rate for Payer: Humana Medicare	$181.19
Rate for Payer: Kaiser Permanente Commercial	$326.13
Rate for Payer: Kaiser Permanente Medicaid	$184.81
Rate for Payer: Kaiser Permanente Medicare	$181.19
Rate for Payer: MDX Hawaii PPO	$351.50
Rate for Payer: Ohana Health Plan Medicaid	$181.19
Rate for Payer: Ohana Health Plan Medicare	$181.19
Rate for Payer: UnitedHealthcare Medicaid	$217.42
Rate for Payer: UnitedHealthcare Medicare	$181.19
Rate for Payer: University Health Alliance Commercial	$264.13

fluticasone 50mcg/spray 16gm nasal [HHSC]

Facility

$397.13

Service Code	NDC 60505082901
Hospital Charge Code	2500339
Hospital Revenue Code	250
Min. Negotiated Rate	$198.56
Max. Negotiated Rate	$385.22
Rate for Payer: AlohaCare Medicaid	$198.56
Rate for Payer: AlohaCare Medicare	$198.56
Rate for Payer: Cash Price	$258.13
Rate for Payer: Devoted Health Medicare	$218.42
Rate for Payer: Hawaii Medical Service Association Medicare	$198.56
Rate for Payer: Hawaii Western Management Group Commercial	$377.27
Rate for Payer: Health Management Network Commercial	$337.56
Rate for Payer: Humana Medicare	$198.56
Rate for Payer: Kaiser Permanente Commercial	$357.42
Rate for Payer: Kaiser Permanente Medicaid	$202.54
Rate for Payer: Kaiser Permanente Medicare	$198.56
Rate for Payer: MDX Hawaii PPO	$385.22
Rate for Payer: Ohana Health Plan Medicaid	$198.56
Rate for Payer: Ohana Health Plan Medicare	$198.56
Rate for Payer: UnitedHealthcare Medicaid	$238.28
Rate for Payer: UnitedHealthcare Medicare	$198.56
Rate for Payer: University Health Alliance Commercial	$289.47

fluticasone 50mcg/spray 16gm nasal [HHSC]

Facility

$362.37

Service Code	NDC 00054327099
Hospital Charge Code	2500339
Hospital Revenue Code	250
Min. Negotiated Rate	$308.01
Max. Negotiated Rate	$351.50
Rate for Payer: Cash Price	$235.54
Rate for Payer: Health Management Network Commercial	$308.01
Rate for Payer: Kaiser Permanente Commercial	$326.13
Rate for Payer: MDX Hawaii PPO	$351.50

fluticasone HFA 110 mcg/inh 12 g inhaler [HHSC]

Facility

$826.95

Service Code	NDC 00173071920
Hospital Charge Code	2500338
Hospital Revenue Code	250
Min. Negotiated Rate	$413.48
Max. Negotiated Rate	$802.14
Rate for Payer: AlohaCare Medicaid	$413.48
Rate for Payer: AlohaCare Medicare	$413.48
Rate for Payer: Cash Price	$537.52
Rate for Payer: Devoted Health Medicare	$454.82
Rate for Payer: Hawaii Medical Service Association Medicare	$413.48
Rate for Payer: Hawaii Western Management Group Commercial	$785.60
Rate for Payer: Health Management Network Commercial	$702.91
Rate for Payer: Humana Medicare	$413.48
Rate for Payer: Kaiser Permanente Commercial	$744.25
Rate for Payer: Kaiser Permanente Medicaid	$421.74
Rate for Payer: Kaiser Permanente Medicare	$413.48
Rate for Payer: MDX Hawaii PPO	$802.14
Rate for Payer: Ohana Health Plan Medicaid	$413.48
Rate for Payer: Ohana Health Plan Medicare	$413.48
Rate for Payer: UnitedHealthcare Medicaid	$496.17
Rate for Payer: UnitedHealthcare Medicare	$413.48
Rate for Payer: University Health Alliance Commercial	$602.76

fluticasone HFA 110 mcg/inh 12 g inhaler [HHSC]

Facility

$826.95

Service Code	NDC 00173071920
Hospital Charge Code	2500338
Hospital Revenue Code	250
Min. Negotiated Rate	$702.91
Max. Negotiated Rate	$802.14
Rate for Payer: Cash Price	$537.52
Rate for Payer: Health Management Network Commercial	$702.91
Rate for Payer: Kaiser Permanente Commercial	$744.25
Rate for Payer: MDX Hawaii PPO	$802.14

fluticasone HFA 110 mcg/inh 12 g inhaler [HHSC]

Facility

$894.44

Service Code	NDC 66993007996
Hospital Charge Code	2500338
Hospital Revenue Code	250
Min. Negotiated Rate	$760.27
Max. Negotiated Rate	$867.61
Rate for Payer: Cash Price	$581.39
Rate for Payer: Health Management Network Commercial	$760.27
Rate for Payer: Kaiser Permanente Commercial	$805.00
Rate for Payer: MDX Hawaii PPO	$867.61

fluticasone HFA 110 mcg/inh 12 g inhaler [HHSC]

Facility

$894.44

Service Code	NDC 66993007996
Hospital Charge Code	2500338
Hospital Revenue Code	250
Min. Negotiated Rate	$447.22
Max. Negotiated Rate	$867.61
Rate for Payer: AlohaCare Medicaid	$447.22
Rate for Payer: AlohaCare Medicare	$447.22
Rate for Payer: Cash Price	$581.39
Rate for Payer: Devoted Health Medicare	$491.94
Rate for Payer: Hawaii Medical Service Association Medicare	$447.22
Rate for Payer: Hawaii Western Management Group Commercial	$849.72
Rate for Payer: Health Management Network Commercial	$760.27
Rate for Payer: Humana Medicare	$447.22
Rate for Payer: Kaiser Permanente Commercial	$805.00
Rate for Payer: Kaiser Permanente Medicaid	$456.16
Rate for Payer: Kaiser Permanente Medicare	$447.22
Rate for Payer: MDX Hawaii PPO	$867.61
Rate for Payer: Ohana Health Plan Medicaid	$447.22
Rate for Payer: Ohana Health Plan Medicare	$447.22
Rate for Payer: UnitedHealthcare Medicaid	$536.66
Rate for Payer: UnitedHealthcare Medicare	$447.22
Rate for Payer: University Health Alliance Commercial	$651.96

fluticasone-salmeterol 250/50 mcg powder 60-ct [HHSC]

Facility

$731.27

Service Code	NDC 00173069604
Hospital Charge Code	2501186
Hospital Revenue Code	250
Min. Negotiated Rate	$365.63
Max. Negotiated Rate	$709.33
Rate for Payer: AlohaCare Medicaid	$365.63
Rate for Payer: AlohaCare Medicare	$365.63
Rate for Payer: Cash Price	$475.33
Rate for Payer: Devoted Health Medicare	$402.20
Rate for Payer: Hawaii Medical Service Association Medicare	$365.63
Rate for Payer: Hawaii Western Management Group Commercial	$694.71
Rate for Payer: Health Management Network Commercial	$621.58
Rate for Payer: Humana Medicare	$365.63
Rate for Payer: Kaiser Permanente Commercial	$658.14
Rate for Payer: Kaiser Permanente Medicaid	$372.95
Rate for Payer: Kaiser Permanente Medicare	$365.63
Rate for Payer: MDX Hawaii PPO	$709.33
Rate for Payer: Ohana Health Plan Medicaid	$365.63
Rate for Payer: Ohana Health Plan Medicare	$365.63
Rate for Payer: UnitedHealthcare Medicaid	$438.76
Rate for Payer: UnitedHealthcare Medicare	$365.63
Rate for Payer: University Health Alliance Commercial	$533.02

fluticasone-salmeterol 250/50 mcg powder 60-ct [HHSC]

Facility

$1,180.58

Service Code	NDC 00054032756
Hospital Charge Code	2501186
Hospital Revenue Code	250
Min. Negotiated Rate	$1,003.49
Max. Negotiated Rate	$1,145.16
Rate for Payer: Cash Price	$767.38
Rate for Payer: Health Management Network Commercial	$1,003.49
Rate for Payer: Kaiser Permanente Commercial	$1,062.52
Rate for Payer: MDX Hawaii PPO	$1,145.16

fluticasone-salmeterol 250/50 mcg powder 60-ct [HHSC]

Facility

$1,180.58

Service Code	NDC 00054032756
Hospital Charge Code	2501186
Hospital Revenue Code	250
Min. Negotiated Rate	$590.29
Max. Negotiated Rate	$1,145.16
Rate for Payer: AlohaCare Medicaid	$590.29
Rate for Payer: AlohaCare Medicare	$590.29
Rate for Payer: Cash Price	$767.38
Rate for Payer: Devoted Health Medicare	$649.32
Rate for Payer: Hawaii Medical Service Association Medicare	$590.29
Rate for Payer: Hawaii Western Management Group Commercial	$1,121.55
Rate for Payer: Health Management Network Commercial	$1,003.49
Rate for Payer: Humana Medicare	$590.29
Rate for Payer: Kaiser Permanente Commercial	$1,062.52
Rate for Payer: Kaiser Permanente Medicaid	$602.10
Rate for Payer: Kaiser Permanente Medicare	$590.29
Rate for Payer: MDX Hawaii PPO	$1,145.16
Rate for Payer: Ohana Health Plan Medicaid	$590.29
Rate for Payer: Ohana Health Plan Medicare	$590.29
Rate for Payer: UnitedHealthcare Medicaid	$708.35
Rate for Payer: UnitedHealthcare Medicare	$590.29
Rate for Payer: University Health Alliance Commercial	$860.52

fluticasone-salmeterol 250/50 mcg powder 60-ct [HHSC]

Facility

$731.27

Service Code	NDC 00173069604
Hospital Charge Code	2501186
Hospital Revenue Code	250
Min. Negotiated Rate	$621.58
Max. Negotiated Rate	$709.33
Rate for Payer: Cash Price	$475.33
Rate for Payer: Health Management Network Commercial	$621.58
Rate for Payer: Kaiser Permanente Commercial	$658.14
Rate for Payer: MDX Hawaii PPO	$709.33

fluticas-umeclid-vilanterol 100-62.5-25 mcg DPI [HHSC]

Facility

$1,010.70

Service Code	NDC 00173088714
Hospital Charge Code	2501150
Hospital Revenue Code	250
Min. Negotiated Rate	$505.35
Max. Negotiated Rate	$980.38
Rate for Payer: AlohaCare Medicaid	$505.35
Rate for Payer: AlohaCare Medicare	$505.35
Rate for Payer: Cash Price	$656.96
Rate for Payer: Devoted Health Medicare	$555.88
Rate for Payer: Hawaii Medical Service Association Medicare	$505.35
Rate for Payer: Hawaii Western Management Group Commercial	$960.16
Rate for Payer: Health Management Network Commercial	$859.10
Rate for Payer: Humana Medicare	$505.35
Rate for Payer: Kaiser Permanente Commercial	$909.63
Rate for Payer: Kaiser Permanente Medicaid	$515.46
Rate for Payer: Kaiser Permanente Medicare	$505.35
Rate for Payer: MDX Hawaii PPO	$980.38
Rate for Payer: Ohana Health Plan Medicaid	$505.35
Rate for Payer: Ohana Health Plan Medicare	$505.35
Rate for Payer: UnitedHealthcare Medicaid	$606.42
Rate for Payer: UnitedHealthcare Medicare	$505.35
Rate for Payer: University Health Alliance Commercial	$736.70

fluticas-umeclid-vilanterol 100-62.5-25 mcg DPI [HHSC]

Facility

$1,010.70

Service Code	NDC 00173088714
Hospital Charge Code	2501150
Hospital Revenue Code	250
Min. Negotiated Rate	$859.10
Max. Negotiated Rate	$980.38
Rate for Payer: Cash Price	$656.96
Rate for Payer: Health Management Network Commercial	$859.10
Rate for Payer: Kaiser Permanente Commercial	$909.63
Rate for Payer: MDX Hawaii PPO	$980.38

FLUTTER VALVE CHARGE

Facility

$173.00

Hospital Charge Code	8243410
Hospital Revenue Code	272
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicare	$86.50
Rate for Payer: Cash Price	$112.45
Rate for Payer: Devoted Health Medicare	$95.15
Rate for Payer: Hawaii Medical Service Association Medicare	$86.50
Rate for Payer: Hawaii Western Management Group Commercial	$164.35
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$86.50
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$86.50
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$86.50
Rate for Payer: Ohana Health Plan Medicare	$86.50
Rate for Payer: UnitedHealthcare Medicare	$86.50
Rate for Payer: University Health Alliance Commercial	$126.10

FLUTTER VALVE CHARGE

Facility

$173.00

Hospital Charge Code	8243410
Hospital Revenue Code	272
Min. Negotiated Rate	$147.05
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$112.45
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$167.81

flu vaccine triv PF (2025-2026) 0.5 mL PFS [HHSC]

Facility

$122.25

Service Code	HCPCS 90656
Hospital Charge Code	2501206
Hospital Revenue Code	250
Min. Negotiated Rate	$103.91
Max. Negotiated Rate	$118.58
Rate for Payer: Cash Price	$79.46
Rate for Payer: Health Management Network Commercial	$103.91
Rate for Payer: Kaiser Permanente Commercial	$110.03
Rate for Payer: MDX Hawaii PPO	$118.58

flu vaccine triv PF (2025-2026) 0.5 mL PFS [HHSC]

Facility

$122.25

Service Code	HCPCS 90656
Hospital Charge Code	2501206
Hospital Revenue Code	636
Min. Negotiated Rate	$22.35
Max. Negotiated Rate	$118.58
Rate for Payer: AlohaCare Medicaid	$61.12
Rate for Payer: AlohaCare Medicare	$61.12
Rate for Payer: Cash Price	$79.46
Rate for Payer: Cash Price	$79.46
Rate for Payer: Devoted Health Medicare	$67.24
Rate for Payer: Hawaii Medical Service Association ABD	$22.35
Rate for Payer: Hawaii Medical Service Association Medicare	$61.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.35
Rate for Payer: Hawaii Western Management Group Commercial	$116.14
Rate for Payer: Health Management Network Commercial	$103.91
Rate for Payer: Humana Medicare	$61.12
Rate for Payer: Kaiser Permanente Commercial	$110.03
Rate for Payer: Kaiser Permanente Medicaid	$62.35
Rate for Payer: Kaiser Permanente Medicare	$61.12
Rate for Payer: MDX Hawaii PPO	$118.58
Rate for Payer: Ohana Health Plan Medicaid	$61.12
Rate for Payer: Ohana Health Plan Medicare	$61.12
Rate for Payer: UnitedHealthcare Medicaid	$73.35
Rate for Payer: UnitedHealthcare Medicare	$61.12
Rate for Payer: University Health Alliance Commercial	$89.11

Fngr Open Wrkhard Roylan

Facility

$103.00

Service Code	HCPCS C1776
Hospital Charge Code	8409629
Hospital Revenue Code	271
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$66.95
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: MDX Hawaii PPO	$99.91

Fngr Open Wrkhard Roylan

Facility

$103.00

Service Code	HCPCS C1776
Hospital Charge Code	8409629
Hospital Revenue Code	271
Min. Negotiated Rate	$51.50
Max. Negotiated Rate	$99.91
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$51.50
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$56.65
Rate for Payer: Hawaii Medical Service Association Medicare	$51.50
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$51.50
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$51.50
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$51.50
Rate for Payer: Ohana Health Plan Medicare	$51.50
Rate for Payer: UnitedHealthcare Medicare	$51.50
Rate for Payer: University Health Alliance Commercial	$75.08

Folate FSI

Facility

$167.00

Service Code	HCPCS 82746
Hospital Charge Code	8117913
Hospital Revenue Code	301
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$161.99
Rate for Payer: AlohaCare Medicaid	$83.50
Rate for Payer: AlohaCare Medicare	$83.50
Rate for Payer: Cash Price	$108.55
Rate for Payer: Cash Price	$108.55
Rate for Payer: Devoted Health Medicare	$91.85
Rate for Payer: Hawaii Medical Service Association ABD	$20.32
Rate for Payer: Hawaii Medical Service Association Commercial	$18.38
Rate for Payer: Hawaii Medical Service Association Medicare	$83.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.34
Rate for Payer: Hawaii Western Management Group Commercial	$14.70
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Humana Medicare	$83.50
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: Kaiser Permanente Medicaid	$85.17
Rate for Payer: Kaiser Permanente Medicare	$83.50
Rate for Payer: MDX Hawaii PPO	$161.99
Rate for Payer: Ohana Health Plan Medicaid	$83.50
Rate for Payer: Ohana Health Plan Medicare	$83.50
Rate for Payer: UnitedHealthcare Medicaid	$20.32
Rate for Payer: UnitedHealthcare Medicare	$83.50
Rate for Payer: University Health Alliance Commercial	$38.00

Folate FSI

Facility

$167.00

Service Code	HCPCS 82746
Hospital Charge Code	8117913
Hospital Revenue Code	301
Min. Negotiated Rate	$141.95
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$108.55
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: MDX Hawaii PPO	$161.99

Folate, RBC FSI

Facility

$196.00

Service Code	HCPCS 82747
Hospital Charge Code	8117914
Hospital Revenue Code	301
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$190.12
Rate for Payer: Cash Price	$127.40
Rate for Payer: Health Management Network Commercial	$166.60
Rate for Payer: Kaiser Permanente Commercial	$176.40
Rate for Payer: MDX Hawaii PPO	$190.12

Folate, RBC FSI

Facility

$196.00

Service Code	HCPCS 82747
Hospital Charge Code	8117914
Hospital Revenue Code	301
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$190.12
Rate for Payer: AlohaCare Medicaid	$98.00
Rate for Payer: AlohaCare Medicare	$98.00
Rate for Payer: Cash Price	$127.40
Rate for Payer: Cash Price	$127.40
Rate for Payer: Devoted Health Medicare	$107.80
Rate for Payer: Hawaii Medical Service Association ABD	$23.93
Rate for Payer: Hawaii Medical Service Association Commercial	$22.06
Rate for Payer: Hawaii Medical Service Association Medicare	$98.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25.13
Rate for Payer: Hawaii Western Management Group Commercial	$17.65
Rate for Payer: Health Management Network Commercial	$166.60
Rate for Payer: Humana Medicare	$98.00
Rate for Payer: Kaiser Permanente Commercial	$176.40
Rate for Payer: Kaiser Permanente Medicaid	$99.96
Rate for Payer: Kaiser Permanente Medicare	$98.00
Rate for Payer: MDX Hawaii PPO	$190.12
Rate for Payer: Ohana Health Plan Medicaid	$98.00
Rate for Payer: Ohana Health Plan Medicare	$98.00
Rate for Payer: UnitedHealthcare Medicaid	$23.93
Rate for Payer: UnitedHealthcare Medicare	$98.00
Rate for Payer: University Health Alliance Commercial	$44.77

Know your out-of-pocket cost for care.

All Charges