Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Gram Smear FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228874
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$11.03

Gram Smear FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228874
Hospital Revenue Code	306
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Gram Stain REF

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8159945
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$11.03

Gram Stain REF

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8159945
Hospital Revenue Code	306
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Group B Strep Carrier Culture FSI

Facility

$90.00

Service Code	HCPCS 87081
Hospital Charge Code	8117928
Hospital Revenue Code	306
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: MDX Hawaii PPO	$87.30

Group B Strep Carrier Culture FSI

Facility

$90.00

Service Code	HCPCS 87081
Hospital Charge Code	8117928
Hospital Revenue Code	306
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$87.30
Rate for Payer: AlohaCare Medicaid	$45.00
Rate for Payer: AlohaCare Medicare	$45.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Devoted Health Medicare	$49.50
Rate for Payer: Hawaii Medical Service Association ABD	$9.16
Rate for Payer: Hawaii Medical Service Association Commercial	$8.29
Rate for Payer: Hawaii Medical Service Association Medicare	$45.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.62
Rate for Payer: Hawaii Western Management Group Commercial	$6.63
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Humana Medicare	$45.00
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicare	$45.00
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: Ohana Health Plan Medicaid	$45.00
Rate for Payer: Ohana Health Plan Medicare	$45.00
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicare	$45.00
Rate for Payer: University Health Alliance Commercial	$17.13

Group B Strep DNA PCR FSI

Facility

$392.00

Service Code	HCPCS 87653
Hospital Charge Code	8117929
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association ABD	$49.04
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.49
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$90.72

Group B Strep DNA PCR FSI

Facility

$392.00

Service Code	HCPCS 87653
Hospital Charge Code	8117929
Hospital Revenue Code	306
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

Group Therapy Charge

Facility

$132.00

Service Code	HCPCS 97150 GP,59
Hospital Charge Code	8111706
Hospital Revenue Code	420
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

Group Therapy Charge

Facility

$132.00

Service Code	HCPCS 97150 GP,59
Hospital Charge Code	8111706
Hospital Revenue Code	420
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$96.21

Group Therapy Provided

Facility

$132.00

Service Code	HCPCS 97150 GP,CQ
Hospital Charge Code	8123863
Hospital Revenue Code	430
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$96.21

Group Therapy Provided

Facility

$132.00

Service Code	HCPCS 97150 GP,CQ
Hospital Charge Code	8123863
Hospital Revenue Code	430
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

guaiFEN-cod 100-10 mg/5 mL 5 mL U/D [HHSC]

Facility

$3.61

Service Code	NDC 00121177500
Hospital Charge Code	2501142
Hospital Revenue Code	250
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$3.50
Rate for Payer: Cash Price	$2.35
Rate for Payer: Health Management Network Commercial	$3.07
Rate for Payer: Kaiser Permanente Commercial	$3.25
Rate for Payer: MDX Hawaii PPO	$3.50

guaiFEN-cod 100-10 mg/5 mL 5 mL U/D [HHSC]

Facility

$3.61

Service Code	NDC 00121177500
Hospital Charge Code	2501142
Hospital Revenue Code	250
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$3.50
Rate for Payer: AlohaCare Medicaid	$1.80
Rate for Payer: AlohaCare Medicare	$1.80
Rate for Payer: Cash Price	$2.35
Rate for Payer: Devoted Health Medicare	$1.99
Rate for Payer: Hawaii Medical Service Association Medicare	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$3.43
Rate for Payer: Health Management Network Commercial	$3.07
Rate for Payer: Humana Medicare	$1.80
Rate for Payer: Kaiser Permanente Commercial	$3.25
Rate for Payer: Kaiser Permanente Medicaid	$1.84
Rate for Payer: Kaiser Permanente Medicare	$1.80
Rate for Payer: MDX Hawaii PPO	$3.50
Rate for Payer: Ohana Health Plan Medicaid	$1.80
Rate for Payer: Ohana Health Plan Medicare	$1.80
Rate for Payer: UnitedHealthcare Medicaid	$2.17
Rate for Payer: UnitedHealthcare Medicare	$1.80
Rate for Payer: University Health Alliance Commercial	$2.63

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$44.15

Service Code	NDC 69543025204
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$37.53
Max. Negotiated Rate	$42.83
Rate for Payer: Cash Price	$28.70
Rate for Payer: Health Management Network Commercial	$37.53
Rate for Payer: Kaiser Permanente Commercial	$39.73
Rate for Payer: MDX Hawaii PPO	$42.83

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$44.10

Service Code	NDC 50383008704
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$37.48
Max. Negotiated Rate	$42.78
Rate for Payer: Cash Price	$28.67
Rate for Payer: Health Management Network Commercial	$37.48
Rate for Payer: Kaiser Permanente Commercial	$39.69
Rate for Payer: MDX Hawaii PPO	$42.78

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$39.11

Service Code	NDC 00121077516
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$37.94
Rate for Payer: AlohaCare Medicaid	$19.55
Rate for Payer: AlohaCare Medicare	$19.55
Rate for Payer: Cash Price	$25.42
Rate for Payer: Devoted Health Medicare	$21.51
Rate for Payer: Hawaii Medical Service Association Medicare	$19.55
Rate for Payer: Hawaii Western Management Group Commercial	$37.15
Rate for Payer: Health Management Network Commercial	$33.24
Rate for Payer: Humana Medicare	$19.55
Rate for Payer: Kaiser Permanente Commercial	$35.20
Rate for Payer: Kaiser Permanente Medicaid	$19.95
Rate for Payer: Kaiser Permanente Medicare	$19.55
Rate for Payer: MDX Hawaii PPO	$37.94
Rate for Payer: Ohana Health Plan Medicaid	$19.55
Rate for Payer: Ohana Health Plan Medicare	$19.55
Rate for Payer: UnitedHealthcare Medicaid	$23.47
Rate for Payer: UnitedHealthcare Medicare	$19.55
Rate for Payer: University Health Alliance Commercial	$28.51

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$44.15

Service Code	NDC 69367027204
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$22.07
Max. Negotiated Rate	$42.83
Rate for Payer: AlohaCare Medicaid	$22.07
Rate for Payer: AlohaCare Medicare	$22.07
Rate for Payer: Cash Price	$28.70
Rate for Payer: Devoted Health Medicare	$24.28
Rate for Payer: Hawaii Medical Service Association Medicare	$22.07
Rate for Payer: Hawaii Western Management Group Commercial	$41.94
Rate for Payer: Health Management Network Commercial	$37.53
Rate for Payer: Humana Medicare	$22.07
Rate for Payer: Kaiser Permanente Commercial	$39.73
Rate for Payer: Kaiser Permanente Medicaid	$22.52
Rate for Payer: Kaiser Permanente Medicare	$22.07
Rate for Payer: MDX Hawaii PPO	$42.83
Rate for Payer: Ohana Health Plan Medicaid	$22.07
Rate for Payer: Ohana Health Plan Medicare	$22.07
Rate for Payer: UnitedHealthcare Medicaid	$26.49
Rate for Payer: UnitedHealthcare Medicare	$22.07
Rate for Payer: University Health Alliance Commercial	$32.18

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$44.15

Service Code	NDC 69367027204
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$37.53
Max. Negotiated Rate	$42.83
Rate for Payer: Cash Price	$28.70
Rate for Payer: Health Management Network Commercial	$37.53
Rate for Payer: Kaiser Permanente Commercial	$39.73
Rate for Payer: MDX Hawaii PPO	$42.83

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$44.10

Service Code	NDC 50383008704
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$42.78
Rate for Payer: AlohaCare Medicaid	$22.05
Rate for Payer: AlohaCare Medicare	$22.05
Rate for Payer: Cash Price	$28.67
Rate for Payer: Devoted Health Medicare	$24.25
Rate for Payer: Hawaii Medical Service Association Medicare	$22.05
Rate for Payer: Hawaii Western Management Group Commercial	$41.90
Rate for Payer: Health Management Network Commercial	$37.48
Rate for Payer: Humana Medicare	$22.05
Rate for Payer: Kaiser Permanente Commercial	$39.69
Rate for Payer: Kaiser Permanente Medicaid	$22.49
Rate for Payer: Kaiser Permanente Medicare	$22.05
Rate for Payer: MDX Hawaii PPO	$42.78
Rate for Payer: Ohana Health Plan Medicaid	$22.05
Rate for Payer: Ohana Health Plan Medicare	$22.05
Rate for Payer: UnitedHealthcare Medicaid	$26.46
Rate for Payer: UnitedHealthcare Medicare	$22.05
Rate for Payer: University Health Alliance Commercial	$32.14

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$44.15

Service Code	NDC 69543025204
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$22.07
Max. Negotiated Rate	$42.83
Rate for Payer: AlohaCare Medicaid	$22.07
Rate for Payer: AlohaCare Medicare	$22.07
Rate for Payer: Cash Price	$28.70
Rate for Payer: Devoted Health Medicare	$24.28
Rate for Payer: Hawaii Medical Service Association Medicare	$22.07
Rate for Payer: Hawaii Western Management Group Commercial	$41.94
Rate for Payer: Health Management Network Commercial	$37.53
Rate for Payer: Humana Medicare	$22.07
Rate for Payer: Kaiser Permanente Commercial	$39.73
Rate for Payer: Kaiser Permanente Medicaid	$22.52
Rate for Payer: Kaiser Permanente Medicare	$22.07
Rate for Payer: MDX Hawaii PPO	$42.83
Rate for Payer: Ohana Health Plan Medicaid	$22.07
Rate for Payer: Ohana Health Plan Medicare	$22.07
Rate for Payer: UnitedHealthcare Medicaid	$26.49
Rate for Payer: UnitedHealthcare Medicare	$22.07
Rate for Payer: University Health Alliance Commercial	$32.18

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$39.11

Service Code	NDC 00121077516
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$33.24
Max. Negotiated Rate	$37.94
Rate for Payer: Cash Price	$25.42
Rate for Payer: Health Management Network Commercial	$33.24
Rate for Payer: Kaiser Permanente Commercial	$35.20
Rate for Payer: MDX Hawaii PPO	$37.94

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$43.28

Service Code	NDC 00121077504
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$21.64
Max. Negotiated Rate	$41.98
Rate for Payer: AlohaCare Medicaid	$21.64
Rate for Payer: AlohaCare Medicare	$21.64
Rate for Payer: Cash Price	$28.13
Rate for Payer: Devoted Health Medicare	$23.80
Rate for Payer: Hawaii Medical Service Association Medicare	$21.64
Rate for Payer: Hawaii Western Management Group Commercial	$41.12
Rate for Payer: Health Management Network Commercial	$36.79
Rate for Payer: Humana Medicare	$21.64
Rate for Payer: Kaiser Permanente Commercial	$38.95
Rate for Payer: Kaiser Permanente Medicaid	$22.07
Rate for Payer: Kaiser Permanente Medicare	$21.64
Rate for Payer: MDX Hawaii PPO	$41.98
Rate for Payer: Ohana Health Plan Medicaid	$21.64
Rate for Payer: Ohana Health Plan Medicare	$21.64
Rate for Payer: UnitedHealthcare Medicaid	$25.97
Rate for Payer: UnitedHealthcare Medicare	$21.64
Rate for Payer: University Health Alliance Commercial	$31.55

guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]

Facility

$43.28

Service Code	NDC 00121077504
Hospital Charge Code	2501122
Hospital Revenue Code	250
Min. Negotiated Rate	$36.79
Max. Negotiated Rate	$41.98
Rate for Payer: Cash Price	$28.13
Rate for Payer: Health Management Network Commercial	$36.79
Rate for Payer: Kaiser Permanente Commercial	$38.95
Rate for Payer: MDX Hawaii PPO	$41.98

guaiFEN-dextro 100-10 mg/5 mL 118ml [HHSC]

Facility

$5.61

Service Code	NDC 57896066116
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$5.44
Rate for Payer: Cash Price	$3.65
Rate for Payer: Health Management Network Commercial	$4.77
Rate for Payer: Kaiser Permanente Commercial	$5.05
Rate for Payer: MDX Hawaii PPO	$5.44

Know your out-of-pocket cost for care.

All Charges