Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

folic acid 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687068101
Hospital Charge Code	2500341
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

folic acid 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687068101
Hospital Charge Code	2500341
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

folic acid 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 62584089701
Hospital Charge Code	2500341
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

folic acid 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 62584089701
Hospital Charge Code	2500341
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

folic acid 50 mg/10ml vial [HHSC]

Facility

$4.86

Service Code	HCPCS J1808
Hospital Charge Code	2500342
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$4.71
Rate for Payer: AlohaCare Medicaid	$2.43
Rate for Payer: AlohaCare Medicaid	$3.01
Rate for Payer: AlohaCare Medicare	$3.01
Rate for Payer: AlohaCare Medicare	$2.43
Rate for Payer: Cash Price	$3.91
Rate for Payer: Cash Price	$3.16
Rate for Payer: Cash Price	$3.16
Rate for Payer: Cash Price	$3.91
Rate for Payer: Devoted Health Medicare	$2.67
Rate for Payer: Devoted Health Medicare	$3.31
Rate for Payer: Hawaii Medical Service Association ABD	$0.06
Rate for Payer: Hawaii Medical Service Association ABD	$0.06
Rate for Payer: Hawaii Medical Service Association Medicare	$3.01
Rate for Payer: Hawaii Medical Service Association Medicare	$2.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.06
Rate for Payer: Hawaii Western Management Group Commercial	$4.62
Rate for Payer: Hawaii Western Management Group Commercial	$5.72
Rate for Payer: Health Management Network Commercial	$5.12
Rate for Payer: Health Management Network Commercial	$4.13
Rate for Payer: Humana Medicare	$2.43
Rate for Payer: Humana Medicare	$3.01
Rate for Payer: Kaiser Permanente Commercial	$4.37
Rate for Payer: Kaiser Permanente Commercial	$5.42
Rate for Payer: Kaiser Permanente Medicaid	$3.07
Rate for Payer: Kaiser Permanente Medicaid	$2.48
Rate for Payer: Kaiser Permanente Medicare	$2.43
Rate for Payer: Kaiser Permanente Medicare	$3.01
Rate for Payer: MDX Hawaii PPO	$4.71
Rate for Payer: MDX Hawaii PPO	$5.84
Rate for Payer: Ohana Health Plan Medicaid	$3.01
Rate for Payer: Ohana Health Plan Medicaid	$2.43
Rate for Payer: Ohana Health Plan Medicare	$2.43
Rate for Payer: Ohana Health Plan Medicare	$3.01
Rate for Payer: UnitedHealthcare Medicaid	$3.61
Rate for Payer: UnitedHealthcare Medicaid	$2.92
Rate for Payer: UnitedHealthcare Medicare	$2.43
Rate for Payer: UnitedHealthcare Medicare	$3.01
Rate for Payer: University Health Alliance Commercial	$3.54
Rate for Payer: University Health Alliance Commercial	$4.39

folic acid 50 mg/10ml vial [HHSC]

Facility

$4.86

Service Code	HCPCS J1808
Hospital Charge Code	2500342
Hospital Revenue Code	250
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$4.71
Rate for Payer: Cash Price	$3.16
Rate for Payer: Cash Price	$3.91
Rate for Payer: Health Management Network Commercial	$4.13
Rate for Payer: Health Management Network Commercial	$5.12
Rate for Payer: Kaiser Permanente Commercial	$4.37
Rate for Payer: Kaiser Permanente Commercial	$5.42
Rate for Payer: MDX Hawaii PPO	$5.84
Rate for Payer: MDX Hawaii PPO	$4.71

fomepizole 1.5 g/1.5ml vial [HHSC]

Facility

$2,557.94

Service Code	HCPCS J1451
Hospital Charge Code	2500343
Hospital Revenue Code	636
Min. Negotiated Rate	$8.18
Max. Negotiated Rate	$2,481.20
Rate for Payer: AlohaCare Medicaid	$1,278.97
Rate for Payer: AlohaCare Medicaid	$1,652.86
Rate for Payer: AlohaCare Medicaid	$1,357.62
Rate for Payer: AlohaCare Medicare	$1,357.62
Rate for Payer: AlohaCare Medicare	$1,278.97
Rate for Payer: AlohaCare Medicare	$1,652.86
Rate for Payer: Cash Price	$1,662.66
Rate for Payer: Cash Price	$1,764.91
Rate for Payer: Cash Price	$1,662.66
Rate for Payer: Cash Price	$2,148.72
Rate for Payer: Cash Price	$2,148.72
Rate for Payer: Cash Price	$1,764.91
Rate for Payer: Devoted Health Medicare	$1,818.15
Rate for Payer: Devoted Health Medicare	$1,493.38
Rate for Payer: Devoted Health Medicare	$1,406.87
Rate for Payer: Hawaii Medical Service Association Commercial	$8.18
Rate for Payer: Hawaii Medical Service Association Commercial	$8.18
Rate for Payer: Hawaii Medical Service Association Commercial	$8.18
Rate for Payer: Hawaii Medical Service Association Medicare	$1,278.97
Rate for Payer: Hawaii Medical Service Association Medicare	$1,357.62
Rate for Payer: Hawaii Medical Service Association Medicare	$1,652.86
Rate for Payer: Hawaii Western Management Group Commercial	$2,579.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,430.04
Rate for Payer: Hawaii Western Management Group Commercial	$3,140.43
Rate for Payer: Health Management Network Commercial	$2,809.86
Rate for Payer: Health Management Network Commercial	$2,174.25
Rate for Payer: Health Management Network Commercial	$2,307.95
Rate for Payer: Humana Medicare	$1,278.97
Rate for Payer: Humana Medicare	$1,357.62
Rate for Payer: Humana Medicare	$1,652.86
Rate for Payer: Kaiser Permanente Commercial	$2,443.72
Rate for Payer: Kaiser Permanente Commercial	$2,302.15
Rate for Payer: Kaiser Permanente Commercial	$2,975.15
Rate for Payer: Kaiser Permanente Medicaid	$1,384.77
Rate for Payer: Kaiser Permanente Medicaid	$1,304.55
Rate for Payer: Kaiser Permanente Medicaid	$1,685.92
Rate for Payer: Kaiser Permanente Medicare	$1,652.86
Rate for Payer: Kaiser Permanente Medicare	$1,357.62
Rate for Payer: Kaiser Permanente Medicare	$1,278.97
Rate for Payer: MDX Hawaii PPO	$2,633.78
Rate for Payer: MDX Hawaii PPO	$2,481.20
Rate for Payer: MDX Hawaii PPO	$3,206.55
Rate for Payer: Ohana Health Plan Medicaid	$1,278.97
Rate for Payer: Ohana Health Plan Medicaid	$1,652.86
Rate for Payer: Ohana Health Plan Medicaid	$1,357.62
Rate for Payer: Ohana Health Plan Medicare	$1,652.86
Rate for Payer: Ohana Health Plan Medicare	$1,278.97
Rate for Payer: Ohana Health Plan Medicare	$1,357.62
Rate for Payer: UnitedHealthcare Medicaid	$1,983.43
Rate for Payer: UnitedHealthcare Medicaid	$1,534.76
Rate for Payer: UnitedHealthcare Medicaid	$1,629.14
Rate for Payer: UnitedHealthcare Medicare	$1,278.97
Rate for Payer: UnitedHealthcare Medicare	$1,652.86
Rate for Payer: UnitedHealthcare Medicare	$1,357.62
Rate for Payer: University Health Alliance Commercial	$2,409.54
Rate for Payer: University Health Alliance Commercial	$1,864.48
Rate for Payer: University Health Alliance Commercial	$1,979.14

fomepizole 1.5 g/1.5ml vial [HHSC]

Facility

$2,557.94

Service Code	HCPCS J1451
Hospital Charge Code	2500343
Hospital Revenue Code	250
Min. Negotiated Rate	$2,174.25
Max. Negotiated Rate	$2,481.20
Rate for Payer: Cash Price	$1,662.66
Rate for Payer: Cash Price	$2,148.72
Rate for Payer: Cash Price	$1,764.91
Rate for Payer: Health Management Network Commercial	$2,174.25
Rate for Payer: Health Management Network Commercial	$2,809.86
Rate for Payer: Health Management Network Commercial	$2,307.95
Rate for Payer: Kaiser Permanente Commercial	$2,302.15
Rate for Payer: Kaiser Permanente Commercial	$2,443.72
Rate for Payer: Kaiser Permanente Commercial	$2,975.15
Rate for Payer: MDX Hawaii PPO	$2,481.20
Rate for Payer: MDX Hawaii PPO	$3,206.55
Rate for Payer: MDX Hawaii PPO	$2,633.78

FOOT PROCEDURES WITH CC

Facility

$24,986.08

Service Code	MSDRG 504
Min. Negotiated Rate	$24,986.08
Max. Negotiated Rate	$24,986.08
Rate for Payer: Hawaii Medical Service Association Commercial	$24,986.08

FOOT PROCEDURES WITH MCC

Facility

$24,986.08

Service Code	MSDRG 503
Min. Negotiated Rate	$24,986.08
Max. Negotiated Rate	$24,986.08
Rate for Payer: Hawaii Medical Service Association Commercial	$24,986.08

FOOT PROCEDURES WITHOUT CC/MCC

Facility

$24,986.08

Service Code	MSDRG 505
Min. Negotiated Rate	$24,986.08
Max. Negotiated Rate	$24,986.08
Rate for Payer: Hawaii Medical Service Association Commercial	$24,986.08

fosphenytoin 500 mg (PE)/10 ml vial [HHSC]

Facility

$491.59

Service Code	HCPCS Q2009
Hospital Charge Code	2500344
Hospital Revenue Code	636
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$476.84
Rate for Payer: AlohaCare Medicaid	$245.79
Rate for Payer: AlohaCare Medicaid	$149.40
Rate for Payer: AlohaCare Medicare	$245.79
Rate for Payer: AlohaCare Medicare	$149.40
Rate for Payer: Cash Price	$194.21
Rate for Payer: Cash Price	$194.21
Rate for Payer: Cash Price	$319.53
Rate for Payer: Cash Price	$319.53
Rate for Payer: Devoted Health Medicare	$270.37
Rate for Payer: Devoted Health Medicare	$164.33
Rate for Payer: Hawaii Medical Service Association Commercial	$1.66
Rate for Payer: Hawaii Medical Service Association Commercial	$1.66
Rate for Payer: Hawaii Medical Service Association Medicare	$245.79
Rate for Payer: Hawaii Medical Service Association Medicare	$149.40
Rate for Payer: Hawaii Western Management Group Commercial	$283.85
Rate for Payer: Hawaii Western Management Group Commercial	$467.01
Rate for Payer: Health Management Network Commercial	$417.85
Rate for Payer: Health Management Network Commercial	$253.97
Rate for Payer: Humana Medicare	$149.40
Rate for Payer: Humana Medicare	$245.79
Rate for Payer: Kaiser Permanente Commercial	$268.91
Rate for Payer: Kaiser Permanente Commercial	$442.43
Rate for Payer: Kaiser Permanente Medicaid	$152.38
Rate for Payer: Kaiser Permanente Medicaid	$250.71
Rate for Payer: Kaiser Permanente Medicare	$245.79
Rate for Payer: Kaiser Permanente Medicare	$149.40
Rate for Payer: MDX Hawaii PPO	$476.84
Rate for Payer: MDX Hawaii PPO	$289.83
Rate for Payer: Ohana Health Plan Medicaid	$245.79
Rate for Payer: Ohana Health Plan Medicaid	$149.40
Rate for Payer: Ohana Health Plan Medicare	$149.40
Rate for Payer: Ohana Health Plan Medicare	$245.79
Rate for Payer: UnitedHealthcare Medicaid	$294.95
Rate for Payer: UnitedHealthcare Medicaid	$179.27
Rate for Payer: UnitedHealthcare Medicare	$149.40
Rate for Payer: UnitedHealthcare Medicare	$245.79
Rate for Payer: University Health Alliance Commercial	$217.79
Rate for Payer: University Health Alliance Commercial	$358.32

fosphenytoin 500 mg (PE)/10 ml vial [HHSC]

Facility

$491.59

Service Code	HCPCS Q2009
Hospital Charge Code	2500344
Hospital Revenue Code	250
Min. Negotiated Rate	$417.85
Max. Negotiated Rate	$476.84
Rate for Payer: Cash Price	$319.53
Rate for Payer: Cash Price	$194.21
Rate for Payer: Health Management Network Commercial	$253.97
Rate for Payer: Health Management Network Commercial	$417.85
Rate for Payer: Kaiser Permanente Commercial	$442.43
Rate for Payer: Kaiser Permanente Commercial	$268.91
Rate for Payer: MDX Hawaii PPO	$289.83
Rate for Payer: MDX Hawaii PPO	$476.84

FRACTURES OF FEMUR WITH MCC

Facility

$13,104.94

Service Code	MSDRG 533
Min. Negotiated Rate	$13,104.94
Max. Negotiated Rate	$13,104.94
Rate for Payer: Hawaii Medical Service Association Commercial	$13,104.94

FRACTURES OF FEMUR WITHOUT MCC

Facility

$13,104.94

Service Code	MSDRG 534
Min. Negotiated Rate	$13,104.94
Max. Negotiated Rate	$13,104.94
Rate for Payer: Hawaii Medical Service Association Commercial	$13,104.94

FRACTURES OF HIP AND PELVIS WITH MCC

Facility

$18,765.06

Service Code	MSDRG 535
Min. Negotiated Rate	$18,765.06
Max. Negotiated Rate	$18,765.06
Rate for Payer: Hawaii Medical Service Association Commercial	$18,765.06

FRACTURES OF HIP AND PELVIS WITHOUT MCC

Facility

$18,765.06

Service Code	MSDRG 536
Min. Negotiated Rate	$18,765.06
Max. Negotiated Rate	$18,765.06
Rate for Payer: Hawaii Medical Service Association Commercial	$18,765.06

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC

Facility

$14,150.28

Service Code	MSDRG 562
Min. Negotiated Rate	$14,150.28
Max. Negotiated Rate	$14,150.28
Rate for Payer: Hawaii Medical Service Association Commercial	$14,150.28

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC

Facility

$14,150.28

Service Code	MSDRG 563
Min. Negotiated Rate	$14,150.28
Max. Negotiated Rate	$14,150.28
Rate for Payer: Hawaii Medical Service Association Commercial	$14,150.28

FREEDOM CANISTER WITH GEL 10/CS

Facility

$155.00

Hospital Charge Code	8444766
Hospital Revenue Code	272
Min. Negotiated Rate	$77.50
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$77.50
Rate for Payer: Cash Price	$100.75
Rate for Payer: Devoted Health Medicare	$85.25
Rate for Payer: Hawaii Medical Service Association Medicare	$77.50
Rate for Payer: Hawaii Western Management Group Commercial	$147.25
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$77.50
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$77.50
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$77.50
Rate for Payer: Ohana Health Plan Medicare	$77.50
Rate for Payer: UnitedHealthcare Medicare	$77.50
Rate for Payer: University Health Alliance Commercial	$112.98

FREEDOM CANISTER WITH GEL 10/CS

Facility

$155.00

Hospital Charge Code	8444766
Hospital Revenue Code	272
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

FREEDOM WOUND VAC GRANUFOAM DRESSING LARGE

Facility

$213.00

Hospital Charge Code	11729002
Hospital Revenue Code	272
Min. Negotiated Rate	$181.05
Max. Negotiated Rate	$206.61
Rate for Payer: Cash Price	$138.45
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$191.70
Rate for Payer: MDX Hawaii PPO	$206.61

FREEDOM WOUND VAC GRANUFOAM DRESSING LARGE

Facility

$213.00

Hospital Charge Code	11729002
Hospital Revenue Code	272
Min. Negotiated Rate	$106.50
Max. Negotiated Rate	$206.61
Rate for Payer: AlohaCare Medicaid	$106.50
Rate for Payer: AlohaCare Medicare	$106.50
Rate for Payer: Cash Price	$138.45
Rate for Payer: Devoted Health Medicare	$117.15
Rate for Payer: Hawaii Medical Service Association Medicare	$106.50
Rate for Payer: Hawaii Western Management Group Commercial	$202.35
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Humana Medicare	$106.50
Rate for Payer: Kaiser Permanente Commercial	$191.70
Rate for Payer: Kaiser Permanente Medicaid	$108.63
Rate for Payer: Kaiser Permanente Medicare	$106.50
Rate for Payer: MDX Hawaii PPO	$206.61
Rate for Payer: Ohana Health Plan Medicaid	$106.50
Rate for Payer: Ohana Health Plan Medicare	$106.50
Rate for Payer: UnitedHealthcare Medicare	$106.50
Rate for Payer: University Health Alliance Commercial	$155.26

Free Light Chain FSI

Facility

$101.00

Service Code	HCPCS 83883
Hospital Charge Code	8228869
Hospital Revenue Code	301
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

Free Light Chain FSI

Facility

$101.00

Service Code	HCPCS 83883
Hospital Charge Code	8228869
Hospital Revenue Code	301
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association ABD	$18.79
Rate for Payer: Hawaii Medical Service Association Commercial	$17.00
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.73
Rate for Payer: Hawaii Western Management Group Commercial	$13.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$18.79
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$35.15

Know your out-of-pocket cost for care.

All Charges