Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$19.63

Service Code	NDC 00904005300
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$19.04
Rate for Payer: AlohaCare Medicaid	$9.81
Rate for Payer: AlohaCare Medicare	$9.81
Rate for Payer: Cash Price	$12.76
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Hawaii Medical Service Association Medicare	$9.81
Rate for Payer: Hawaii Western Management Group Commercial	$18.65
Rate for Payer: Health Management Network Commercial	$16.69
Rate for Payer: Humana Medicare	$9.81
Rate for Payer: Kaiser Permanente Commercial	$17.67
Rate for Payer: Kaiser Permanente Medicaid	$10.01
Rate for Payer: Kaiser Permanente Medicare	$9.81
Rate for Payer: MDX Hawaii PPO	$19.04
Rate for Payer: Ohana Health Plan Medicaid	$9.81
Rate for Payer: Ohana Health Plan Medicare	$9.81
Rate for Payer: UnitedHealthcare Medicaid	$11.78
Rate for Payer: UnitedHealthcare Medicare	$9.81
Rate for Payer: University Health Alliance Commercial	$14.31

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

Facility

$29.63

Service Code	NDC 54838020940
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$14.81
Max. Negotiated Rate	$28.74
Rate for Payer: AlohaCare Medicaid	$14.81
Rate for Payer: AlohaCare Medicare	$14.81
Rate for Payer: Cash Price	$19.26
Rate for Payer: Devoted Health Medicare	$16.30
Rate for Payer: Hawaii Medical Service Association Medicare	$14.81
Rate for Payer: Hawaii Western Management Group Commercial	$28.15
Rate for Payer: Health Management Network Commercial	$25.19
Rate for Payer: Humana Medicare	$14.81
Rate for Payer: Kaiser Permanente Commercial	$26.67
Rate for Payer: Kaiser Permanente Medicaid	$15.11
Rate for Payer: Kaiser Permanente Medicare	$14.81
Rate for Payer: MDX Hawaii PPO	$28.74
Rate for Payer: Ohana Health Plan Medicaid	$14.81
Rate for Payer: Ohana Health Plan Medicare	$14.81
Rate for Payer: UnitedHealthcare Medicaid	$17.78
Rate for Payer: UnitedHealthcare Medicare	$14.81
Rate for Payer: University Health Alliance Commercial	$21.60

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

Facility

$12.72

Service Code	NDC 00904646420
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$10.81
Max. Negotiated Rate	$12.34
Rate for Payer: Cash Price	$8.27
Rate for Payer: Health Management Network Commercial	$10.81
Rate for Payer: Kaiser Permanente Commercial	$11.45
Rate for Payer: MDX Hawaii PPO	$12.34

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

Facility

$42.81

Service Code	NDC 24385057826
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$36.39
Max. Negotiated Rate	$41.53
Rate for Payer: Cash Price	$27.83
Rate for Payer: Health Management Network Commercial	$36.39
Rate for Payer: Kaiser Permanente Commercial	$38.53
Rate for Payer: MDX Hawaii PPO	$41.53

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

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

Facility

$12.13

Service Code	NDC 71399100408
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$6.07
Max. Negotiated Rate	$11.77
Rate for Payer: AlohaCare Medicaid	$6.07
Rate for Payer: AlohaCare Medicare	$6.07
Rate for Payer: Cash Price	$7.88
Rate for Payer: Devoted Health Medicare	$6.67
Rate for Payer: Hawaii Medical Service Association Medicare	$6.07
Rate for Payer: Hawaii Western Management Group Commercial	$11.52
Rate for Payer: Health Management Network Commercial	$10.31
Rate for Payer: Humana Medicare	$6.07
Rate for Payer: Kaiser Permanente Commercial	$10.92
Rate for Payer: Kaiser Permanente Medicaid	$6.19
Rate for Payer: Kaiser Permanente Medicare	$6.07
Rate for Payer: MDX Hawaii PPO	$11.77
Rate for Payer: Ohana Health Plan Medicaid	$6.07
Rate for Payer: Ohana Health Plan Medicare	$6.07
Rate for Payer: UnitedHealthcare Medicaid	$7.28
Rate for Payer: UnitedHealthcare Medicare	$6.07
Rate for Payer: University Health Alliance Commercial	$8.84

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

Facility

$12.13

Service Code	NDC 71399100408
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$10.31
Max. Negotiated Rate	$11.77
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Management Network Commercial	$10.31
Rate for Payer: Kaiser Permanente Commercial	$10.92
Rate for Payer: MDX Hawaii PPO	$11.77

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	$2.81
Max. Negotiated Rate	$5.44
Rate for Payer: AlohaCare Medicaid	$2.81
Rate for Payer: AlohaCare Medicare	$2.81
Rate for Payer: Cash Price	$3.65
Rate for Payer: Devoted Health Medicare	$3.09
Rate for Payer: Hawaii Medical Service Association Medicare	$2.81
Rate for Payer: Hawaii Western Management Group Commercial	$5.33
Rate for Payer: Health Management Network Commercial	$4.77
Rate for Payer: Humana Medicare	$2.81
Rate for Payer: Kaiser Permanente Commercial	$5.05
Rate for Payer: Kaiser Permanente Medicaid	$2.86
Rate for Payer: Kaiser Permanente Medicare	$2.81
Rate for Payer: MDX Hawaii PPO	$5.44
Rate for Payer: Ohana Health Plan Medicaid	$2.81
Rate for Payer: Ohana Health Plan Medicare	$2.81
Rate for Payer: UnitedHealthcare Medicaid	$3.37
Rate for Payer: UnitedHealthcare Medicare	$2.81
Rate for Payer: University Health Alliance Commercial	$4.09

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

Facility

$12.72

Service Code	NDC 00904646420
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$12.34
Rate for Payer: AlohaCare Medicaid	$6.36
Rate for Payer: AlohaCare Medicare	$6.36
Rate for Payer: Cash Price	$8.27
Rate for Payer: Devoted Health Medicare	$7.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6.36
Rate for Payer: Hawaii Western Management Group Commercial	$12.08
Rate for Payer: Health Management Network Commercial	$10.81
Rate for Payer: Humana Medicare	$6.36
Rate for Payer: Kaiser Permanente Commercial	$11.45
Rate for Payer: Kaiser Permanente Medicaid	$6.49
Rate for Payer: Kaiser Permanente Medicare	$6.36
Rate for Payer: MDX Hawaii PPO	$12.34
Rate for Payer: Ohana Health Plan Medicaid	$6.36
Rate for Payer: Ohana Health Plan Medicare	$6.36
Rate for Payer: UnitedHealthcare Medicaid	$7.63
Rate for Payer: UnitedHealthcare Medicare	$6.36
Rate for Payer: University Health Alliance Commercial	$9.27

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

Facility

$8.45

Service Code	NDC 24385035926
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$8.20
Rate for Payer: AlohaCare Medicaid	$4.22
Rate for Payer: AlohaCare Medicare	$4.22
Rate for Payer: Cash Price	$5.49
Rate for Payer: Devoted Health Medicare	$4.65
Rate for Payer: Hawaii Medical Service Association Medicare	$4.22
Rate for Payer: Hawaii Western Management Group Commercial	$8.03
Rate for Payer: Health Management Network Commercial	$7.18
Rate for Payer: Humana Medicare	$4.22
Rate for Payer: Kaiser Permanente Commercial	$7.61
Rate for Payer: Kaiser Permanente Medicaid	$4.31
Rate for Payer: Kaiser Permanente Medicare	$4.22
Rate for Payer: MDX Hawaii PPO	$8.20
Rate for Payer: Ohana Health Plan Medicaid	$4.22
Rate for Payer: Ohana Health Plan Medicare	$4.22
Rate for Payer: UnitedHealthcare Medicaid	$5.07
Rate for Payer: UnitedHealthcare Medicare	$4.22
Rate for Payer: University Health Alliance Commercial	$6.16

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

Facility

$8.11

Service Code	NDC 71399002606
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$7.87
Rate for Payer: AlohaCare Medicaid	$4.05
Rate for Payer: AlohaCare Medicare	$4.05
Rate for Payer: Cash Price	$5.27
Rate for Payer: Devoted Health Medicare	$4.46
Rate for Payer: Hawaii Medical Service Association Medicare	$4.05
Rate for Payer: Hawaii Western Management Group Commercial	$7.70
Rate for Payer: Health Management Network Commercial	$6.89
Rate for Payer: Humana Medicare	$4.05
Rate for Payer: Kaiser Permanente Commercial	$7.30
Rate for Payer: Kaiser Permanente Medicaid	$4.14
Rate for Payer: Kaiser Permanente Medicare	$4.05
Rate for Payer: MDX Hawaii PPO	$7.87
Rate for Payer: Ohana Health Plan Medicaid	$4.05
Rate for Payer: Ohana Health Plan Medicare	$4.05
Rate for Payer: UnitedHealthcare Medicaid	$4.87
Rate for Payer: UnitedHealthcare Medicare	$4.05
Rate for Payer: University Health Alliance Commercial	$5.91

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

Facility

$8.45

Service Code	NDC 24385035926
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$8.20
Rate for Payer: Cash Price	$5.49
Rate for Payer: Health Management Network Commercial	$7.18
Rate for Payer: Kaiser Permanente Commercial	$7.61
Rate for Payer: MDX Hawaii PPO	$8.20

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

Facility

$29.74

Service Code	NDC 55505011133
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$14.87
Max. Negotiated Rate	$28.85
Rate for Payer: AlohaCare Medicaid	$14.87
Rate for Payer: AlohaCare Medicare	$14.87
Rate for Payer: Cash Price	$19.33
Rate for Payer: Devoted Health Medicare	$16.36
Rate for Payer: Hawaii Medical Service Association Medicare	$14.87
Rate for Payer: Hawaii Western Management Group Commercial	$28.25
Rate for Payer: Health Management Network Commercial	$25.28
Rate for Payer: Humana Medicare	$14.87
Rate for Payer: Kaiser Permanente Commercial	$26.77
Rate for Payer: Kaiser Permanente Medicaid	$15.17
Rate for Payer: Kaiser Permanente Medicare	$14.87
Rate for Payer: MDX Hawaii PPO	$28.85
Rate for Payer: Ohana Health Plan Medicaid	$14.87
Rate for Payer: Ohana Health Plan Medicare	$14.87
Rate for Payer: UnitedHealthcare Medicaid	$17.84
Rate for Payer: UnitedHealthcare Medicare	$14.87
Rate for Payer: University Health Alliance Commercial	$21.68

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

Facility

$8.11

Service Code	NDC 71399002606
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$7.87
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Management Network Commercial	$6.89
Rate for Payer: Kaiser Permanente Commercial	$7.30
Rate for Payer: MDX Hawaii PPO	$7.87

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

Facility

$29.74

Service Code	NDC 55505011133
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$25.28
Max. Negotiated Rate	$28.85
Rate for Payer: Cash Price	$19.33
Rate for Payer: Health Management Network Commercial	$25.28
Rate for Payer: Kaiser Permanente Commercial	$26.77
Rate for Payer: MDX Hawaii PPO	$28.85

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

Facility

$29.63

Service Code	NDC 54838020940
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$25.19
Max. Negotiated Rate	$28.74
Rate for Payer: Cash Price	$19.26
Rate for Payer: Health Management Network Commercial	$25.19
Rate for Payer: Kaiser Permanente Commercial	$26.67
Rate for Payer: MDX Hawaii PPO	$28.74

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

Facility

$19.63

Service Code	NDC 00904005300
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$16.69
Max. Negotiated Rate	$19.04
Rate for Payer: Cash Price	$12.76
Rate for Payer: Health Management Network Commercial	$16.69
Rate for Payer: Kaiser Permanente Commercial	$17.67
Rate for Payer: MDX Hawaii PPO	$19.04

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$40.34

Service Code	NDC 46122029926
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$34.29
Max. Negotiated Rate	$39.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Health Management Network Commercial	$34.29
Rate for Payer: Kaiser Permanente Commercial	$36.31
Rate for Payer: MDX Hawaii PPO	$39.13

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$14.68

Service Code	NDC 00904006100
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$14.24
Rate for Payer: Cash Price	$9.54
Rate for Payer: Health Management Network Commercial	$12.48
Rate for Payer: Kaiser Permanente Commercial	$13.21
Rate for Payer: MDX Hawaii PPO	$14.24

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$6.33

Service Code	NDC 00904676320
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$6.14
Rate for Payer: AlohaCare Medicaid	$3.17
Rate for Payer: AlohaCare Medicare	$3.17
Rate for Payer: Cash Price	$4.11
Rate for Payer: Devoted Health Medicare	$3.48
Rate for Payer: Hawaii Medical Service Association Medicare	$3.17
Rate for Payer: Hawaii Western Management Group Commercial	$6.01
Rate for Payer: Health Management Network Commercial	$5.38
Rate for Payer: Humana Medicare	$3.17
Rate for Payer: Kaiser Permanente Commercial	$5.70
Rate for Payer: Kaiser Permanente Medicaid	$3.23
Rate for Payer: Kaiser Permanente Medicare	$3.17
Rate for Payer: MDX Hawaii PPO	$6.14
Rate for Payer: Ohana Health Plan Medicaid	$3.17
Rate for Payer: Ohana Health Plan Medicare	$3.17
Rate for Payer: UnitedHealthcare Medicaid	$3.80
Rate for Payer: UnitedHealthcare Medicare	$3.17
Rate for Payer: University Health Alliance Commercial	$4.61

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$6.33

Service Code	NDC 00904676320
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$6.14
Rate for Payer: Cash Price	$4.11
Rate for Payer: Health Management Network Commercial	$5.38
Rate for Payer: Kaiser Permanente Commercial	$5.70
Rate for Payer: MDX Hawaii PPO	$6.14

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$11.99

Service Code	NDC 00536118297
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$11.63
Rate for Payer: Cash Price	$7.79
Rate for Payer: Health Management Network Commercial	$10.19
Rate for Payer: Kaiser Permanente Commercial	$10.79
Rate for Payer: MDX Hawaii PPO	$11.63

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$40.34

Service Code	NDC 46122029926
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$39.13
Rate for Payer: AlohaCare Medicaid	$20.17
Rate for Payer: AlohaCare Medicare	$20.17
Rate for Payer: Cash Price	$26.22
Rate for Payer: Devoted Health Medicare	$22.19
Rate for Payer: Hawaii Medical Service Association Medicare	$20.17
Rate for Payer: Hawaii Western Management Group Commercial	$38.32
Rate for Payer: Health Management Network Commercial	$34.29
Rate for Payer: Humana Medicare	$20.17
Rate for Payer: Kaiser Permanente Commercial	$36.31
Rate for Payer: Kaiser Permanente Medicaid	$20.57
Rate for Payer: Kaiser Permanente Medicare	$20.17
Rate for Payer: MDX Hawaii PPO	$39.13
Rate for Payer: Ohana Health Plan Medicaid	$20.17
Rate for Payer: Ohana Health Plan Medicare	$20.17
Rate for Payer: UnitedHealthcare Medicaid	$24.20
Rate for Payer: UnitedHealthcare Medicare	$20.17
Rate for Payer: University Health Alliance Commercial	$29.40

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$14.08

Service Code	NDC 54838011740
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$13.66
Rate for Payer: Cash Price	$9.15
Rate for Payer: Health Management Network Commercial	$11.97
Rate for Payer: Kaiser Permanente Commercial	$12.67
Rate for Payer: MDX Hawaii PPO	$13.66

guaiFENesin 100 mg/5 mL 118ml [HHSC]

Facility

$6.76

Service Code	NDC 57896069316
Hospital Charge Code	2500368
Hospital Revenue Code	250
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$6.56
Rate for Payer: AlohaCare Medicaid	$3.38
Rate for Payer: AlohaCare Medicare	$3.38
Rate for Payer: Cash Price	$4.39
Rate for Payer: Devoted Health Medicare	$3.72
Rate for Payer: Hawaii Medical Service Association Medicare	$3.38
Rate for Payer: Hawaii Western Management Group Commercial	$6.42
Rate for Payer: Health Management Network Commercial	$5.75
Rate for Payer: Humana Medicare	$3.38
Rate for Payer: Kaiser Permanente Commercial	$6.08
Rate for Payer: Kaiser Permanente Medicaid	$3.45
Rate for Payer: Kaiser Permanente Medicare	$3.38
Rate for Payer: MDX Hawaii PPO	$6.56
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.38
Rate for Payer: UnitedHealthcare Medicaid	$4.06
Rate for Payer: UnitedHealthcare Medicare	$3.38
Rate for Payer: University Health Alliance Commercial	$4.93

Know your out-of-pocket cost for care.

All Charges