Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

GI SNARE, COLONOSCOPY ROTATABLE

Facility

$96.00

Hospital Charge Code	8274288
Hospital Revenue Code	272
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$93.12
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$48.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$48.00
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$48.00
Rate for Payer: Ohana Health Plan Medicare	$48.00
Rate for Payer: UnitedHealthcare Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$69.97

GI SNARE, COLONOSCOPY ROTATABLE

Facility

$96.00

Hospital Charge Code	8274288
Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12

GI SNARE, ENDOSCOPY 240 CAPTIVATOR LARGE OVAL THIN WIRE FLEXIBLE 30MM

Facility

$89.00

Hospital Charge Code	8274444
Hospital Revenue Code	272
Min. Negotiated Rate	$44.50
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$44.50
Rate for Payer: Cash Price	$57.85
Rate for Payer: Devoted Health Medicare	$48.95
Rate for Payer: Hawaii Medical Service Association Medicare	$44.50
Rate for Payer: Hawaii Western Management Group Commercial	$84.55
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$44.50
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$44.50
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$44.50
Rate for Payer: Ohana Health Plan Medicare	$44.50
Rate for Payer: UnitedHealthcare Medicare	$44.50
Rate for Payer: University Health Alliance Commercial	$64.87

GI SNARE, ENDOSCOPY 240 CAPTIVATOR LARGE OVAL THIN WIRE FLEXIBLE 30MM

Facility

$89.00

Hospital Charge Code	8274444
Hospital Revenue Code	272
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

GI SNARE, MASTER

Facility

$72.00

Hospital Charge Code	8274301
Hospital Revenue Code	272
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

GI SNARE, MASTER

Facility

$72.00

Hospital Charge Code	8274301
Hospital Revenue Code	272
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$36.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Devoted Health Medicare	$39.60
Rate for Payer: Hawaii Medical Service Association Medicare	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$68.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$36.00
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$36.00
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$36.00
Rate for Payer: Ohana Health Plan Medicare	$36.00
Rate for Payer: UnitedHealthcare Medicare	$36.00
Rate for Payer: University Health Alliance Commercial	$52.48

GI: SNARE, MEDIUM

Facility

$108.00

Hospital Charge Code	9953069
Hospital Revenue Code	272
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$70.20
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: MDX Hawaii PPO	$104.76

GI: SNARE, MEDIUM

Facility

$108.00

Hospital Charge Code	9953069
Hospital Revenue Code	272
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$104.76
Rate for Payer: AlohaCare Medicaid	$54.00
Rate for Payer: AlohaCare Medicare	$54.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Devoted Health Medicare	$59.40
Rate for Payer: Hawaii Medical Service Association Medicare	$54.00
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Humana Medicare	$54.00
Rate for Payer: Kaiser Permanente Commercial	$97.20
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: Kaiser Permanente Medicare	$54.00
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: Ohana Health Plan Medicaid	$54.00
Rate for Payer: Ohana Health Plan Medicare	$54.00
Rate for Payer: UnitedHealthcare Medicare	$54.00
Rate for Payer: University Health Alliance Commercial	$78.72

glipiZIDE 10 mg tablet [HHSC]

Facility

$4.22

Service Code	NDC 51079081120
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$4.09
Rate for Payer: Cash Price	$2.74
Rate for Payer: Health Management Network Commercial	$3.59
Rate for Payer: Kaiser Permanente Commercial	$3.80
Rate for Payer: MDX Hawaii PPO	$4.09

glipiZIDE 10 mg tablet [HHSC]

Facility

$4.22

Service Code	NDC 51079081120
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$4.09
Rate for Payer: AlohaCare Medicaid	$2.11
Rate for Payer: AlohaCare Medicare	$2.11
Rate for Payer: Cash Price	$2.74
Rate for Payer: Devoted Health Medicare	$2.32
Rate for Payer: Hawaii Medical Service Association Medicare	$2.11
Rate for Payer: Hawaii Western Management Group Commercial	$4.01
Rate for Payer: Health Management Network Commercial	$3.59
Rate for Payer: Humana Medicare	$2.11
Rate for Payer: Kaiser Permanente Commercial	$3.80
Rate for Payer: Kaiser Permanente Medicaid	$2.15
Rate for Payer: Kaiser Permanente Medicare	$2.11
Rate for Payer: MDX Hawaii PPO	$4.09
Rate for Payer: Ohana Health Plan Medicaid	$2.11
Rate for Payer: Ohana Health Plan Medicare	$2.11
Rate for Payer: UnitedHealthcare Medicaid	$2.53
Rate for Payer: UnitedHealthcare Medicare	$2.11
Rate for Payer: University Health Alliance Commercial	$3.08

glipiZIDE 10 mg tablet [HHSC]

Facility

$3.72

Service Code	NDC 60505014200
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$3.61
Rate for Payer: AlohaCare Medicaid	$1.86
Rate for Payer: AlohaCare Medicare	$1.86
Rate for Payer: Cash Price	$2.42
Rate for Payer: Devoted Health Medicare	$2.05
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
Rate for Payer: Hawaii Western Management Group Commercial	$3.53
Rate for Payer: Health Management Network Commercial	$3.16
Rate for Payer: Humana Medicare	$1.86
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: Kaiser Permanente Medicaid	$1.90
Rate for Payer: Kaiser Permanente Medicare	$1.86
Rate for Payer: MDX Hawaii PPO	$3.61
Rate for Payer: Ohana Health Plan Medicaid	$1.86
Rate for Payer: Ohana Health Plan Medicare	$1.86
Rate for Payer: UnitedHealthcare Medicaid	$2.23
Rate for Payer: UnitedHealthcare Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$2.71

glipiZIDE 10 mg tablet [HHSC]

Facility

$4.22

Service Code	NDC 50268036215
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$4.09
Rate for Payer: Cash Price	$2.74
Rate for Payer: Health Management Network Commercial	$3.59
Rate for Payer: Kaiser Permanente Commercial	$3.80
Rate for Payer: MDX Hawaii PPO	$4.09

glipiZIDE 10 mg tablet [HHSC]

Facility

$3.72

Service Code	NDC 60505014200
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$3.61
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Management Network Commercial	$3.16
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: MDX Hawaii PPO	$3.61

glipiZIDE 10 mg tablet [HHSC]

Facility

$4.22

Service Code	NDC 50268036215
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$4.09
Rate for Payer: AlohaCare Medicaid	$2.11
Rate for Payer: AlohaCare Medicare	$2.11
Rate for Payer: Cash Price	$2.74
Rate for Payer: Devoted Health Medicare	$2.32
Rate for Payer: Hawaii Medical Service Association Medicare	$2.11
Rate for Payer: Hawaii Western Management Group Commercial	$4.01
Rate for Payer: Health Management Network Commercial	$3.59
Rate for Payer: Humana Medicare	$2.11
Rate for Payer: Kaiser Permanente Commercial	$3.80
Rate for Payer: Kaiser Permanente Medicaid	$2.15
Rate for Payer: Kaiser Permanente Medicare	$2.11
Rate for Payer: MDX Hawaii PPO	$4.09
Rate for Payer: Ohana Health Plan Medicaid	$2.11
Rate for Payer: Ohana Health Plan Medicare	$2.11
Rate for Payer: UnitedHealthcare Medicaid	$2.53
Rate for Payer: UnitedHealthcare Medicare	$2.11
Rate for Payer: University Health Alliance Commercial	$3.08

glipiZIDE 10 mg tablet [HHSC]

Facility

$3.56

Service Code	NDC 60687070101
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$3.45
Rate for Payer: AlohaCare Medicaid	$1.78
Rate for Payer: AlohaCare Medicare	$1.78
Rate for Payer: Cash Price	$2.31
Rate for Payer: Devoted Health Medicare	$1.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1.78
Rate for Payer: Hawaii Western Management Group Commercial	$3.38
Rate for Payer: Health Management Network Commercial	$3.03
Rate for Payer: Humana Medicare	$1.78
Rate for Payer: Kaiser Permanente Commercial	$3.20
Rate for Payer: Kaiser Permanente Medicaid	$1.82
Rate for Payer: Kaiser Permanente Medicare	$1.78
Rate for Payer: MDX Hawaii PPO	$3.45
Rate for Payer: Ohana Health Plan Medicaid	$1.78
Rate for Payer: Ohana Health Plan Medicare	$1.78
Rate for Payer: UnitedHealthcare Medicaid	$2.14
Rate for Payer: UnitedHealthcare Medicare	$1.78
Rate for Payer: University Health Alliance Commercial	$2.59

glipiZIDE 10 mg tablet [HHSC]

Facility

$3.56

Service Code	NDC 60687070101
Hospital Charge Code	2500356
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$3.45
Rate for Payer: Cash Price	$2.31
Rate for Payer: Health Management Network Commercial	$3.03
Rate for Payer: Kaiser Permanente Commercial	$3.20
Rate for Payer: MDX Hawaii PPO	$3.45

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079081020
Hospital Charge Code	2500357
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687069001
Hospital Charge Code	2500357
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60505014100
Hospital Charge Code	2500357
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687069001
Hospital Charge Code	2500357
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60505014100
Hospital Charge Code	2500357
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 50268036115
Hospital Charge Code	2500357
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 50268036115
Hospital Charge Code	2500357
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

glipiZIDE 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079081020
Hospital Charge Code	2500357
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

glucagon 1 mg kit [HHSC]

Facility

$939.34

Service Code	HCPCS J1610
Hospital Charge Code	2500358
Hospital Revenue Code	250
Min. Negotiated Rate	$798.44
Max. Negotiated Rate	$911.16
Rate for Payer: Cash Price	$610.57
Rate for Payer: Cash Price	$613.76
Rate for Payer: Health Management Network Commercial	$798.44
Rate for Payer: Health Management Network Commercial	$802.60
Rate for Payer: Kaiser Permanente Commercial	$849.82
Rate for Payer: Kaiser Permanente Commercial	$845.41
Rate for Payer: MDX Hawaii PPO	$911.16
Rate for Payer: MDX Hawaii PPO	$915.91

Know your out-of-pocket cost for care.

All Charges