Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

glycerin infant 2.8 g/4 mL enema [HHSC]

Facility

$7.43

Service Code	NDC 00132019012
Hospital Charge Code	2501078
Hospital Revenue Code	250
Min. Negotiated Rate	$6.32
Max. Negotiated Rate	$7.21
Rate for Payer: Cash Price	$4.83
Rate for Payer: Health Management Network Commercial	$6.32
Rate for Payer: Kaiser Permanente Commercial	$6.69
Rate for Payer: MDX Hawaii PPO	$7.21

glycerin infant 2.8 g/4 mL enema [HHSC]

Facility

$7.43

Service Code	NDC 00132019012
Hospital Charge Code	2501078
Hospital Revenue Code	250
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$7.21
Rate for Payer: AlohaCare Medicaid	$3.71
Rate for Payer: AlohaCare Medicare	$3.71
Rate for Payer: Cash Price	$4.83
Rate for Payer: Devoted Health Medicare	$4.09
Rate for Payer: Hawaii Medical Service Association Medicare	$3.71
Rate for Payer: Hawaii Western Management Group Commercial	$7.06
Rate for Payer: Health Management Network Commercial	$6.32
Rate for Payer: Humana Medicare	$3.71
Rate for Payer: Kaiser Permanente Commercial	$6.69
Rate for Payer: Kaiser Permanente Medicaid	$3.79
Rate for Payer: Kaiser Permanente Medicare	$3.71
Rate for Payer: MDX Hawaii PPO	$7.21
Rate for Payer: Ohana Health Plan Medicaid	$3.71
Rate for Payer: Ohana Health Plan Medicare	$3.71
Rate for Payer: UnitedHealthcare Medicaid	$4.46
Rate for Payer: UnitedHealthcare Medicare	$3.71
Rate for Payer: University Health Alliance Commercial	$5.42

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$45.10

Service Code	NDC 00143968225
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$38.34
Max. Negotiated Rate	$43.75
Rate for Payer: Cash Price	$29.32
Rate for Payer: Health Management Network Commercial	$38.34
Rate for Payer: Kaiser Permanente Commercial	$40.59
Rate for Payer: MDX Hawaii PPO	$43.75

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$83.36

Service Code	NDC 00143958725
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$41.68
Max. Negotiated Rate	$80.86
Rate for Payer: AlohaCare Medicaid	$41.68
Rate for Payer: AlohaCare Medicare	$41.68
Rate for Payer: Cash Price	$54.18
Rate for Payer: Devoted Health Medicare	$45.85
Rate for Payer: Hawaii Medical Service Association Medicare	$41.68
Rate for Payer: Hawaii Western Management Group Commercial	$79.19
Rate for Payer: Health Management Network Commercial	$70.86
Rate for Payer: Humana Medicare	$41.68
Rate for Payer: Kaiser Permanente Commercial	$75.02
Rate for Payer: Kaiser Permanente Medicaid	$42.51
Rate for Payer: Kaiser Permanente Medicare	$41.68
Rate for Payer: MDX Hawaii PPO	$80.86
Rate for Payer: Ohana Health Plan Medicaid	$41.68
Rate for Payer: Ohana Health Plan Medicare	$41.68
Rate for Payer: UnitedHealthcare Medicaid	$50.02
Rate for Payer: UnitedHealthcare Medicare	$41.68
Rate for Payer: University Health Alliance Commercial	$60.76

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$45.10

Service Code	NDC 00143968225
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$43.75
Rate for Payer: AlohaCare Medicaid	$22.55
Rate for Payer: AlohaCare Medicare	$22.55
Rate for Payer: Cash Price	$29.32
Rate for Payer: Devoted Health Medicare	$24.80
Rate for Payer: Hawaii Medical Service Association Medicare	$22.55
Rate for Payer: Hawaii Western Management Group Commercial	$42.84
Rate for Payer: Health Management Network Commercial	$38.34
Rate for Payer: Humana Medicare	$22.55
Rate for Payer: Kaiser Permanente Commercial	$40.59
Rate for Payer: Kaiser Permanente Medicaid	$23.00
Rate for Payer: Kaiser Permanente Medicare	$22.55
Rate for Payer: MDX Hawaii PPO	$43.75
Rate for Payer: Ohana Health Plan Medicaid	$22.55
Rate for Payer: Ohana Health Plan Medicare	$22.55
Rate for Payer: UnitedHealthcare Medicaid	$27.06
Rate for Payer: UnitedHealthcare Medicare	$22.55
Rate for Payer: University Health Alliance Commercial	$32.87

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$18.15

Service Code	NDC 43547054325
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$15.43
Max. Negotiated Rate	$17.61
Rate for Payer: Cash Price	$11.80
Rate for Payer: Health Management Network Commercial	$15.43
Rate for Payer: Kaiser Permanente Commercial	$16.34
Rate for Payer: MDX Hawaii PPO	$17.61

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$4.74

Service Code	NDC 71288041492
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$4.60
Rate for Payer: Cash Price	$3.08
Rate for Payer: Health Management Network Commercial	$4.03
Rate for Payer: Kaiser Permanente Commercial	$4.27
Rate for Payer: MDX Hawaii PPO	$4.60

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$18.63

Service Code	NDC 70069001125
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$18.07
Rate for Payer: Cash Price	$12.11
Rate for Payer: Health Management Network Commercial	$15.84
Rate for Payer: Kaiser Permanente Commercial	$16.77
Rate for Payer: MDX Hawaii PPO	$18.07

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$18.15

Service Code	NDC 43547054325
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$9.07
Max. Negotiated Rate	$17.61
Rate for Payer: AlohaCare Medicaid	$9.07
Rate for Payer: AlohaCare Medicare	$9.07
Rate for Payer: Cash Price	$11.80
Rate for Payer: Devoted Health Medicare	$9.98
Rate for Payer: Hawaii Medical Service Association Medicare	$9.07
Rate for Payer: Hawaii Western Management Group Commercial	$17.24
Rate for Payer: Health Management Network Commercial	$15.43
Rate for Payer: Humana Medicare	$9.07
Rate for Payer: Kaiser Permanente Commercial	$16.34
Rate for Payer: Kaiser Permanente Medicaid	$9.26
Rate for Payer: Kaiser Permanente Medicare	$9.07
Rate for Payer: MDX Hawaii PPO	$17.61
Rate for Payer: Ohana Health Plan Medicaid	$9.07
Rate for Payer: Ohana Health Plan Medicare	$9.07
Rate for Payer: UnitedHealthcare Medicaid	$10.89
Rate for Payer: UnitedHealthcare Medicare	$9.07
Rate for Payer: University Health Alliance Commercial	$13.23

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$83.36

Service Code	NDC 00143958725
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$70.86
Max. Negotiated Rate	$80.86
Rate for Payer: Cash Price	$54.18
Rate for Payer: Health Management Network Commercial	$70.86
Rate for Payer: Kaiser Permanente Commercial	$75.02
Rate for Payer: MDX Hawaii PPO	$80.86

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$86.07

Service Code	NDC 00517460125
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$73.16
Max. Negotiated Rate	$83.49
Rate for Payer: Cash Price	$55.95
Rate for Payer: Health Management Network Commercial	$73.16
Rate for Payer: Kaiser Permanente Commercial	$77.46
Rate for Payer: MDX Hawaii PPO	$83.49

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$18.63

Service Code	NDC 70069001125
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$9.31
Max. Negotiated Rate	$18.07
Rate for Payer: AlohaCare Medicaid	$9.31
Rate for Payer: AlohaCare Medicare	$9.31
Rate for Payer: Cash Price	$12.11
Rate for Payer: Devoted Health Medicare	$10.25
Rate for Payer: Hawaii Medical Service Association Medicare	$9.31
Rate for Payer: Hawaii Western Management Group Commercial	$17.70
Rate for Payer: Health Management Network Commercial	$15.84
Rate for Payer: Humana Medicare	$9.31
Rate for Payer: Kaiser Permanente Commercial	$16.77
Rate for Payer: Kaiser Permanente Medicaid	$9.50
Rate for Payer: Kaiser Permanente Medicare	$9.31
Rate for Payer: MDX Hawaii PPO	$18.07
Rate for Payer: Ohana Health Plan Medicaid	$9.31
Rate for Payer: Ohana Health Plan Medicare	$9.31
Rate for Payer: UnitedHealthcare Medicaid	$11.18
Rate for Payer: UnitedHealthcare Medicare	$9.31
Rate for Payer: University Health Alliance Commercial	$13.58

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$45.30

Service Code	NDC 16729047108
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$22.65
Max. Negotiated Rate	$43.94
Rate for Payer: AlohaCare Medicaid	$22.65
Rate for Payer: AlohaCare Medicare	$22.65
Rate for Payer: Cash Price	$29.44
Rate for Payer: Devoted Health Medicare	$24.91
Rate for Payer: Hawaii Medical Service Association Medicare	$22.65
Rate for Payer: Hawaii Western Management Group Commercial	$43.03
Rate for Payer: Health Management Network Commercial	$38.51
Rate for Payer: Humana Medicare	$22.65
Rate for Payer: Kaiser Permanente Commercial	$40.77
Rate for Payer: Kaiser Permanente Medicaid	$23.10
Rate for Payer: Kaiser Permanente Medicare	$22.65
Rate for Payer: MDX Hawaii PPO	$43.94
Rate for Payer: Ohana Health Plan Medicaid	$22.65
Rate for Payer: Ohana Health Plan Medicare	$22.65
Rate for Payer: UnitedHealthcare Medicaid	$27.18
Rate for Payer: UnitedHealthcare Medicare	$22.65
Rate for Payer: University Health Alliance Commercial	$33.02

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$18.15

Service Code	NDC 43547063925
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$9.07
Max. Negotiated Rate	$17.61
Rate for Payer: AlohaCare Medicaid	$9.07
Rate for Payer: AlohaCare Medicare	$9.07
Rate for Payer: Cash Price	$11.80
Rate for Payer: Devoted Health Medicare	$9.98
Rate for Payer: Hawaii Medical Service Association Medicare	$9.07
Rate for Payer: Hawaii Western Management Group Commercial	$17.24
Rate for Payer: Health Management Network Commercial	$15.43
Rate for Payer: Humana Medicare	$9.07
Rate for Payer: Kaiser Permanente Commercial	$16.34
Rate for Payer: Kaiser Permanente Medicaid	$9.26
Rate for Payer: Kaiser Permanente Medicare	$9.07
Rate for Payer: MDX Hawaii PPO	$17.61
Rate for Payer: Ohana Health Plan Medicaid	$9.07
Rate for Payer: Ohana Health Plan Medicare	$9.07
Rate for Payer: UnitedHealthcare Medicaid	$10.89
Rate for Payer: UnitedHealthcare Medicare	$9.07
Rate for Payer: University Health Alliance Commercial	$13.23

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$4.74

Service Code	NDC 71288041492
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$4.60
Rate for Payer: AlohaCare Medicaid	$2.37
Rate for Payer: AlohaCare Medicare	$2.37
Rate for Payer: Cash Price	$3.08
Rate for Payer: Devoted Health Medicare	$2.61
Rate for Payer: Hawaii Medical Service Association Medicare	$2.37
Rate for Payer: Hawaii Western Management Group Commercial	$4.50
Rate for Payer: Health Management Network Commercial	$4.03
Rate for Payer: Humana Medicare	$2.37
Rate for Payer: Kaiser Permanente Commercial	$4.27
Rate for Payer: Kaiser Permanente Medicaid	$2.42
Rate for Payer: Kaiser Permanente Medicare	$2.37
Rate for Payer: MDX Hawaii PPO	$4.60
Rate for Payer: Ohana Health Plan Medicaid	$2.37
Rate for Payer: Ohana Health Plan Medicare	$2.37
Rate for Payer: UnitedHealthcare Medicaid	$2.84
Rate for Payer: UnitedHealthcare Medicare	$2.37
Rate for Payer: University Health Alliance Commercial	$3.45

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$86.07

Service Code	NDC 00517460125
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$43.03
Max. Negotiated Rate	$83.49
Rate for Payer: AlohaCare Medicaid	$43.03
Rate for Payer: AlohaCare Medicare	$43.03
Rate for Payer: Cash Price	$55.95
Rate for Payer: Devoted Health Medicare	$47.34
Rate for Payer: Hawaii Medical Service Association Medicare	$43.03
Rate for Payer: Hawaii Western Management Group Commercial	$81.77
Rate for Payer: Health Management Network Commercial	$73.16
Rate for Payer: Humana Medicare	$43.03
Rate for Payer: Kaiser Permanente Commercial	$77.46
Rate for Payer: Kaiser Permanente Medicaid	$43.90
Rate for Payer: Kaiser Permanente Medicare	$43.03
Rate for Payer: MDX Hawaii PPO	$83.49
Rate for Payer: Ohana Health Plan Medicaid	$43.03
Rate for Payer: Ohana Health Plan Medicare	$43.03
Rate for Payer: UnitedHealthcare Medicaid	$51.64
Rate for Payer: UnitedHealthcare Medicare	$43.03
Rate for Payer: University Health Alliance Commercial	$62.74

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$18.15

Service Code	NDC 43547063925
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$15.43
Max. Negotiated Rate	$17.61
Rate for Payer: Cash Price	$11.80
Rate for Payer: Health Management Network Commercial	$15.43
Rate for Payer: Kaiser Permanente Commercial	$16.34
Rate for Payer: MDX Hawaii PPO	$17.61

glycopyrrolate 0.2 mg/1ml vial [HHSC]

Facility

$45.30

Service Code	NDC 16729047108
Hospital Charge Code	2500366
Hospital Revenue Code	250
Min. Negotiated Rate	$38.51
Max. Negotiated Rate	$43.94
Rate for Payer: Cash Price	$29.44
Rate for Payer: Health Management Network Commercial	$38.51
Rate for Payer: Kaiser Permanente Commercial	$40.77
Rate for Payer: MDX Hawaii PPO	$43.94

GONIOTOMY

Facility

$11,119.00

Service Code	CPT 65820
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,119.00
Rate for Payer: AlohaCare Medicaid	$672.48
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$11,119.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$4,035.20

GRAFT, SKIN DERMACARRIER II, 1.5:1

Facility

$169.00

Hospital Charge Code	8274154
Hospital Revenue Code	272
Min. Negotiated Rate	$84.50
Max. Negotiated Rate	$163.93
Rate for Payer: AlohaCare Medicaid	$84.50
Rate for Payer: AlohaCare Medicare	$84.50
Rate for Payer: Cash Price	$109.85
Rate for Payer: Devoted Health Medicare	$92.95
Rate for Payer: Hawaii Medical Service Association Medicare	$84.50
Rate for Payer: Hawaii Western Management Group Commercial	$160.55
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Humana Medicare	$84.50
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicare	$84.50
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: Ohana Health Plan Medicaid	$84.50
Rate for Payer: Ohana Health Plan Medicare	$84.50
Rate for Payer: UnitedHealthcare Medicare	$84.50
Rate for Payer: University Health Alliance Commercial	$123.18

GRAFT, SKIN DERMACARRIER II, 1.5:1

Facility

$169.00

Hospital Charge Code	8274154
Hospital Revenue Code	272
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$109.85
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: MDX Hawaii PPO	$163.93

GRAFT, SKIN DERMACARRIER II, 3: 1

Facility

$2,025.00

Hospital Charge Code	8274155
Hospital Revenue Code	272
Min. Negotiated Rate	$1,721.25
Max. Negotiated Rate	$1,964.25
Rate for Payer: Cash Price	$1,316.25
Rate for Payer: Health Management Network Commercial	$1,721.25
Rate for Payer: Kaiser Permanente Commercial	$1,822.50
Rate for Payer: MDX Hawaii PPO	$1,964.25

GRAFT, SKIN DERMACARRIER II, 3: 1

Facility

$2,025.00

Hospital Charge Code	8274155
Hospital Revenue Code	272
Min. Negotiated Rate	$1,012.50
Max. Negotiated Rate	$1,964.25
Rate for Payer: AlohaCare Medicaid	$1,012.50
Rate for Payer: AlohaCare Medicare	$1,012.50
Rate for Payer: Cash Price	$1,316.25
Rate for Payer: Devoted Health Medicare	$1,113.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,012.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,923.75
Rate for Payer: Health Management Network Commercial	$1,721.25
Rate for Payer: Humana Medicare	$1,012.50
Rate for Payer: Kaiser Permanente Commercial	$1,822.50
Rate for Payer: Kaiser Permanente Medicaid	$1,032.75
Rate for Payer: Kaiser Permanente Medicare	$1,012.50
Rate for Payer: MDX Hawaii PPO	$1,964.25
Rate for Payer: Ohana Health Plan Medicaid	$1,012.50
Rate for Payer: Ohana Health Plan Medicare	$1,012.50
Rate for Payer: UnitedHealthcare Medicare	$1,012.50
Rate for Payer: University Health Alliance Commercial	$1,476.02

GRAFT, SKIN DERMATOME BLADES

Facility

$214.00

Hospital Charge Code	8274156
Hospital Revenue Code	272
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

GRAFT, SKIN DERMATOME BLADES

Facility

$214.00

Hospital Charge Code	8274156
Hospital Revenue Code	272
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$207.58
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$155.98

Know your out-of-pocket cost for care.

All Charges