Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

GUIDE WIRE, TROCAR TIP, 1.35 MM

Facility

$25.00

Service Code	HCPCS C1769
Hospital Charge Code	12944032
Hospital Revenue Code	272
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

GYN: ALLY UPS ADAPTER DRAPE

Facility

$617.00

Hospital Charge Code	11584047
Hospital Revenue Code	272
Min. Negotiated Rate	$308.50
Max. Negotiated Rate	$598.49
Rate for Payer: AlohaCare Medicaid	$308.50
Rate for Payer: AlohaCare Medicare	$308.50
Rate for Payer: Cash Price	$401.05
Rate for Payer: Devoted Health Medicare	$339.35
Rate for Payer: Hawaii Medical Service Association Medicare	$308.50
Rate for Payer: Hawaii Western Management Group Commercial	$586.15
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Humana Medicare	$308.50
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: Kaiser Permanente Medicaid	$314.67
Rate for Payer: Kaiser Permanente Medicare	$308.50
Rate for Payer: MDX Hawaii PPO	$598.49
Rate for Payer: Ohana Health Plan Medicaid	$308.50
Rate for Payer: Ohana Health Plan Medicare	$308.50
Rate for Payer: UnitedHealthcare Medicare	$308.50
Rate for Payer: University Health Alliance Commercial	$449.73

GYN: ALLY UPS ADAPTER DRAPE

Facility

$617.00

Hospital Charge Code	11584047
Hospital Revenue Code	272
Min. Negotiated Rate	$524.45
Max. Negotiated Rate	$598.49
Rate for Payer: Cash Price	$401.05
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: MDX Hawaii PPO	$598.49

GYN BIOPSY PUNCH 5MM

Facility

$160.00

Hospital Charge Code	8274370
Hospital Revenue Code	272
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

GYN BIOPSY PUNCH 5MM

Facility

$160.00

Hospital Charge Code	8274370
Hospital Revenue Code	272
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$116.62

GYN CAUTERY, ELECTRODES LEEP 10MM X 10MM LOOP

Facility

$76.00

Hospital Charge Code	8274274
Hospital Revenue Code	272
Min. Negotiated Rate	$38.00
Max. Negotiated Rate	$73.72
Rate for Payer: AlohaCare Medicaid	$38.00
Rate for Payer: AlohaCare Medicare	$38.00
Rate for Payer: Cash Price	$49.40
Rate for Payer: Devoted Health Medicare	$41.80
Rate for Payer: Hawaii Medical Service Association Medicare	$38.00
Rate for Payer: Hawaii Western Management Group Commercial	$72.20
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Humana Medicare	$38.00
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: Kaiser Permanente Medicaid	$38.76
Rate for Payer: Kaiser Permanente Medicare	$38.00
Rate for Payer: MDX Hawaii PPO	$73.72
Rate for Payer: Ohana Health Plan Medicaid	$38.00
Rate for Payer: Ohana Health Plan Medicare	$38.00
Rate for Payer: UnitedHealthcare Medicare	$38.00
Rate for Payer: University Health Alliance Commercial	$55.40

GYN CAUTERY, ELECTRODES LEEP 10MM X 10MM LOOP

Facility

$76.00

Hospital Charge Code	8274274
Hospital Revenue Code	272
Min. Negotiated Rate	$64.60
Max. Negotiated Rate	$73.72
Rate for Payer: Cash Price	$49.40
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$68.40
Rate for Payer: MDX Hawaii PPO	$73.72

GYN CURRETTE, DISPOSABLE VAGINAL 10mm CURVED

Facility

$29.00

Hospital Charge Code	8274157
Hospital Revenue Code	272
Min. Negotiated Rate	$14.50
Max. Negotiated Rate	$28.13
Rate for Payer: AlohaCare Medicaid	$14.50
Rate for Payer: AlohaCare Medicare	$14.50
Rate for Payer: Cash Price	$18.85
Rate for Payer: Devoted Health Medicare	$15.95
Rate for Payer: Hawaii Medical Service Association Medicare	$14.50
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Humana Medicare	$14.50
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: Kaiser Permanente Medicare	$14.50
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: Ohana Health Plan Medicaid	$14.50
Rate for Payer: Ohana Health Plan Medicare	$14.50
Rate for Payer: UnitedHealthcare Medicare	$14.50
Rate for Payer: University Health Alliance Commercial	$21.14

GYN CURRETTE, DISPOSABLE VAGINAL 10mm CURVED

Facility

$29.00

Hospital Charge Code	8274157
Hospital Revenue Code	272
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$18.85
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$26.10
Rate for Payer: MDX Hawaii PPO	$28.13

GYN CURRETTE, DISPOSABLE VAGINAL 16mm CURVED

Facility

$34.00

Hospital Charge Code	8274158
Hospital Revenue Code	272
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$17.00
Rate for Payer: Cash Price	$22.10
Rate for Payer: Devoted Health Medicare	$18.70
Rate for Payer: Hawaii Medical Service Association Medicare	$17.00
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$17.00
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$17.00
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$17.00
Rate for Payer: Ohana Health Plan Medicare	$17.00
Rate for Payer: UnitedHealthcare Medicare	$17.00
Rate for Payer: University Health Alliance Commercial	$24.78

GYN CURRETTE, DISPOSABLE VAGINAL 16mm CURVED

Facility

$34.00

Hospital Charge Code	8274158
Hospital Revenue Code	272
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

GYN CURRETTE, DISPOSABLE VAGINAL 6mm CURVED

Facility

$26.00

Hospital Charge Code	8274159
Hospital Revenue Code	272
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$13.00
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$14.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.00
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$13.00
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$13.00
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$13.00
Rate for Payer: Ohana Health Plan Medicare	$13.00
Rate for Payer: UnitedHealthcare Medicare	$13.00
Rate for Payer: University Health Alliance Commercial	$18.95

GYN CURRETTE, DISPOSABLE VAGINAL 6mm CURVED

Facility

$26.00

Hospital Charge Code	8274159
Hospital Revenue Code	272
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$16.90
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

GYN CURRETTE, DISPOSABLE VAGINAL 8mm CURVED

Facility

$26.00

Hospital Charge Code	8274160
Hospital Revenue Code	272
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$25.22
Rate for Payer: Cash Price	$16.90
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: MDX Hawaii PPO	$25.22

GYN CURRETTE, DISPOSABLE VAGINAL 8mm CURVED

Facility

$26.00

Hospital Charge Code	8274160
Hospital Revenue Code	272
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$25.22
Rate for Payer: AlohaCare Medicaid	$13.00
Rate for Payer: AlohaCare Medicare	$13.00
Rate for Payer: Cash Price	$16.90
Rate for Payer: Devoted Health Medicare	$14.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.00
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Humana Medicare	$13.00
Rate for Payer: Kaiser Permanente Commercial	$23.40
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: Kaiser Permanente Medicare	$13.00
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: Ohana Health Plan Medicaid	$13.00
Rate for Payer: Ohana Health Plan Medicare	$13.00
Rate for Payer: UnitedHealthcare Medicare	$13.00
Rate for Payer: University Health Alliance Commercial	$18.95

GYNECOLOGY:NEEDLE WILLIAMS CYSTOSCOPIC INJECTION 23

Facility

$159.00

Hospital Charge Code	13242247
Hospital Revenue Code	272
Min. Negotiated Rate	$79.50
Max. Negotiated Rate	$154.23
Rate for Payer: AlohaCare Medicaid	$79.50
Rate for Payer: AlohaCare Medicare	$79.50
Rate for Payer: Cash Price	$103.35
Rate for Payer: Devoted Health Medicare	$87.45
Rate for Payer: Hawaii Medical Service Association Medicare	$79.50
Rate for Payer: Hawaii Western Management Group Commercial	$151.05
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Humana Medicare	$79.50
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: Kaiser Permanente Medicaid	$81.09
Rate for Payer: Kaiser Permanente Medicare	$79.50
Rate for Payer: MDX Hawaii PPO	$154.23
Rate for Payer: Ohana Health Plan Medicaid	$79.50
Rate for Payer: Ohana Health Plan Medicare	$79.50
Rate for Payer: UnitedHealthcare Medicare	$79.50
Rate for Payer: University Health Alliance Commercial	$115.90

GYNECOLOGY:NEEDLE WILLIAMS CYSTOSCOPIC INJECTION 23

Facility

$159.00

Hospital Charge Code	13242247
Hospital Revenue Code	272
Min. Negotiated Rate	$135.15
Max. Negotiated Rate	$154.23
Rate for Payer: Cash Price	$103.35
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: MDX Hawaii PPO	$154.23

GYN:ENSEAL X1 CURVED

Facility

$2,875.00

Hospital Charge Code	11754479
Hospital Revenue Code	272
Min. Negotiated Rate	$2,443.75
Max. Negotiated Rate	$2,788.75
Rate for Payer: Cash Price	$1,868.75
Rate for Payer: Health Management Network Commercial	$2,443.75
Rate for Payer: Kaiser Permanente Commercial	$2,587.50
Rate for Payer: MDX Hawaii PPO	$2,788.75

GYN:ENSEAL X1 CURVED

Facility

$2,875.00

Hospital Charge Code	11754479
Hospital Revenue Code	272
Min. Negotiated Rate	$1,437.50
Max. Negotiated Rate	$2,788.75
Rate for Payer: AlohaCare Medicaid	$1,437.50
Rate for Payer: AlohaCare Medicare	$1,437.50
Rate for Payer: Cash Price	$1,868.75
Rate for Payer: Devoted Health Medicare	$1,581.25
Rate for Payer: Hawaii Medical Service Association Medicare	$1,437.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,731.25
Rate for Payer: Health Management Network Commercial	$2,443.75
Rate for Payer: Humana Medicare	$1,437.50
Rate for Payer: Kaiser Permanente Commercial	$2,587.50
Rate for Payer: Kaiser Permanente Medicaid	$1,466.25
Rate for Payer: Kaiser Permanente Medicare	$1,437.50
Rate for Payer: MDX Hawaii PPO	$2,788.75
Rate for Payer: Ohana Health Plan Medicaid	$1,437.50
Rate for Payer: Ohana Health Plan Medicare	$1,437.50
Rate for Payer: UnitedHealthcare Medicare	$1,437.50
Rate for Payer: University Health Alliance Commercial	$2,095.59

GYN:HOLOGIC FLUENT

Facility

$1,397.00

Hospital Charge Code	11461982
Hospital Revenue Code	270
Min. Negotiated Rate	$698.50
Max. Negotiated Rate	$1,355.09
Rate for Payer: AlohaCare Medicaid	$698.50
Rate for Payer: AlohaCare Medicare	$698.50
Rate for Payer: Cash Price	$908.05
Rate for Payer: Devoted Health Medicare	$768.35
Rate for Payer: Hawaii Medical Service Association Medicare	$698.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,327.15
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Humana Medicare	$698.50
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: Kaiser Permanente Medicaid	$712.47
Rate for Payer: Kaiser Permanente Medicare	$698.50
Rate for Payer: MDX Hawaii PPO	$1,355.09
Rate for Payer: Ohana Health Plan Medicaid	$698.50
Rate for Payer: Ohana Health Plan Medicare	$698.50
Rate for Payer: UnitedHealthcare Medicare	$698.50
Rate for Payer: University Health Alliance Commercial	$1,018.27

GYN:HOLOGIC FLUENT

Facility

$1,397.00

Hospital Charge Code	11461982
Hospital Revenue Code	270
Min. Negotiated Rate	$1,187.45
Max. Negotiated Rate	$1,355.09
Rate for Payer: Cash Price	$908.05
Rate for Payer: Health Management Network Commercial	$1,187.45
Rate for Payer: Kaiser Permanente Commercial	$1,257.30
Rate for Payer: MDX Hawaii PPO	$1,355.09

Haemophilus influenza B, IgG FSI

Facility

$183.00

Service Code	HCPCS 86684
Hospital Charge Code	9300200
Hospital Revenue Code	300
Min. Negotiated Rate	$13.28
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$91.50
Rate for Payer: Cash Price	$118.95
Rate for Payer: Cash Price	$118.95
Rate for Payer: Devoted Health Medicare	$100.65
Rate for Payer: Hawaii Medical Service Association ABD	$13.28
Rate for Payer: Hawaii Medical Service Association Commercial	$19.80
Rate for Payer: Hawaii Medical Service Association Medicare	$91.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.89
Rate for Payer: Hawaii Western Management Group Commercial	$15.84
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$91.50
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$91.50
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$91.50
Rate for Payer: Ohana Health Plan Medicare	$91.50
Rate for Payer: UnitedHealthcare Medicaid	$13.28
Rate for Payer: UnitedHealthcare Medicare	$91.50
Rate for Payer: University Health Alliance Commercial	$40.96

Haemophilus influenza B, IgG FSI

Facility

$183.00

Service Code	HCPCS 86684
Hospital Charge Code	9300200
Hospital Revenue Code	300
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$118.95
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

haloperidol 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079073420
Hospital Charge Code	2500370
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

haloperidol 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079073420
Hospital Charge Code	2500370
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

Know your out-of-pocket cost for care.

All Charges