Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Immunoglobulin IgG SO

Facility

$63.00

Service Code	HCPCS 82784
Hospital Charge Code	9699802
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Immunoglobulin IgG SO

Facility

$63.00

Service Code	HCPCS 82784
Hospital Charge Code	9699802
Hospital Revenue Code	301
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$10.55
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.08
Rate for Payer: Hawaii Western Management Group Commercial	$9.30
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$10.55
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$19.74

Immunoglobulin IgM SO

Facility

$63.00

Service Code	HCPCS 82784
Hospital Charge Code	9699803
Hospital Revenue Code	301
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$10.55
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.08
Rate for Payer: Hawaii Western Management Group Commercial	$9.30
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$10.55
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$19.74

Immunoglobulin IgM SO

Facility

$63.00

Service Code	HCPCS 82784
Hospital Charge Code	9699803
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Immunoglobulin Panel (IgG, IgA, IgM) FSI

Facility

$78.00

Service Code	HCPCS 82784
Hospital Charge Code	9699800
Hospital Revenue Code	301
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association ABD	$10.55
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.08
Rate for Payer: Hawaii Western Management Group Commercial	$9.30
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$10.55
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$19.74

Immunoglobulin Panel (IgG, IgA, IgM) FSI

Facility

$78.00

Service Code	HCPCS 82784
Hospital Charge Code	9699800
Hospital Revenue Code	301
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

INBORN AND OTHER DISORDERS OF METABOLISM

Facility

$91,785.60

Service Code	MSDRG 642
Min. Negotiated Rate	$91,785.60
Max. Negotiated Rate	$91,785.60
Rate for Payer: Hawaii Medical Service Association Commercial	$91,785.60

INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS

Facility

$2,837.00

Service Code	CPT 56420
Hospital Revenue Code	360
Min. Negotiated Rate	$63.97
Max. Negotiated Rate	$2,837.00
Rate for Payer: Hawaii Medical Service Association Commercial	$258.19
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$63.97

Incision and drainage of submucosal abscess, rectum

Facility

$1,551.00

Service Code	HCPCS 45005
Hospital Charge Code	8848346
Hospital Revenue Code	450
Min. Negotiated Rate	$1,318.35
Max. Negotiated Rate	$1,504.47
Rate for Payer: Cash Price	$1,008.15
Rate for Payer: Health Management Network Commercial	$1,318.35
Rate for Payer: Kaiser Permanente Commercial	$1,395.90
Rate for Payer: MDX Hawaii PPO	$1,504.47

Incision and drainage of submucosal abscess, rectum

Facility

$1,551.00

Service Code	HCPCS 45005
Hospital Charge Code	8848346
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: AlohaCare Medicare	$775.50
Rate for Payer: Cash Price	$1,008.15
Rate for Payer: Cash Price	$1,008.15
Rate for Payer: Devoted Health Medicare	$853.05
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$775.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,473.45
Rate for Payer: Health Management Network Commercial	$1,318.35
Rate for Payer: Humana Medicare	$775.50
Rate for Payer: Kaiser Permanente Commercial	$1,395.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$775.50
Rate for Payer: MDX Hawaii PPO	$1,504.47
Rate for Payer: Ohana Health Plan Medicaid	$775.50
Rate for Payer: Ohana Health Plan Medicare	$775.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$775.50
Rate for Payer: University Health Alliance Commercial	$5,160.40

indocyanine green 25 mg vial [HHSC]

Facility

$545.00

Service Code	NDC 17478070102
Hospital Charge Code	2501000
Hospital Revenue Code	250
Min. Negotiated Rate	$272.50
Max. Negotiated Rate	$528.65
Rate for Payer: AlohaCare Medicaid	$272.50
Rate for Payer: AlohaCare Medicare	$272.50
Rate for Payer: Cash Price	$354.25
Rate for Payer: Devoted Health Medicare	$299.75
Rate for Payer: Hawaii Medical Service Association Medicare	$272.50
Rate for Payer: Hawaii Western Management Group Commercial	$517.75
Rate for Payer: Health Management Network Commercial	$463.25
Rate for Payer: Humana Medicare	$272.50
Rate for Payer: Kaiser Permanente Commercial	$490.50
Rate for Payer: Kaiser Permanente Medicaid	$277.95
Rate for Payer: Kaiser Permanente Medicare	$272.50
Rate for Payer: MDX Hawaii PPO	$528.65
Rate for Payer: Ohana Health Plan Medicaid	$272.50
Rate for Payer: Ohana Health Plan Medicare	$272.50
Rate for Payer: UnitedHealthcare Medicaid	$327.00
Rate for Payer: UnitedHealthcare Medicare	$272.50
Rate for Payer: University Health Alliance Commercial	$397.25

indocyanine green 25 mg vial [HHSC]

Facility

$545.00

Service Code	NDC 17478070102
Hospital Charge Code	2501000
Hospital Revenue Code	250
Min. Negotiated Rate	$463.25
Max. Negotiated Rate	$528.65
Rate for Payer: Cash Price	$354.25
Rate for Payer: Health Management Network Commercial	$463.25
Rate for Payer: Kaiser Permanente Commercial	$490.50
Rate for Payer: MDX Hawaii PPO	$528.65

indocyanine green 25 mg vial [HHSC]

Facility

$444.80

Service Code	NDC 17238042406
Hospital Charge Code	2501000
Hospital Revenue Code	250
Min. Negotiated Rate	$378.08
Max. Negotiated Rate	$431.46
Rate for Payer: Cash Price	$289.12
Rate for Payer: Health Management Network Commercial	$378.08
Rate for Payer: Kaiser Permanente Commercial	$400.32
Rate for Payer: MDX Hawaii PPO	$431.46

indocyanine green 25 mg vial [HHSC]

Facility

$444.80

Service Code	NDC 17238042406
Hospital Charge Code	2501000
Hospital Revenue Code	250
Min. Negotiated Rate	$222.40
Max. Negotiated Rate	$431.46
Rate for Payer: AlohaCare Medicaid	$222.40
Rate for Payer: AlohaCare Medicare	$222.40
Rate for Payer: Cash Price	$289.12
Rate for Payer: Devoted Health Medicare	$244.64
Rate for Payer: Hawaii Medical Service Association Medicare	$222.40
Rate for Payer: Hawaii Western Management Group Commercial	$422.56
Rate for Payer: Health Management Network Commercial	$378.08
Rate for Payer: Humana Medicare	$222.40
Rate for Payer: Kaiser Permanente Commercial	$400.32
Rate for Payer: Kaiser Permanente Medicaid	$226.85
Rate for Payer: Kaiser Permanente Medicare	$222.40
Rate for Payer: MDX Hawaii PPO	$431.46
Rate for Payer: Ohana Health Plan Medicaid	$222.40
Rate for Payer: Ohana Health Plan Medicare	$222.40
Rate for Payer: UnitedHealthcare Medicaid	$266.88
Rate for Payer: UnitedHealthcare Medicare	$222.40
Rate for Payer: University Health Alliance Commercial	$324.21

indomethacin 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 68462040601
Hospital Charge Code	2500413
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

indomethacin 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 50268043015
Hospital Charge Code	2500413
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

indomethacin 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 51079019020
Hospital Charge Code	2500413
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

indomethacin 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 50268043015
Hospital Charge Code	2500413
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

indomethacin 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 51079019020
Hospital Charge Code	2500413
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

indomethacin 25 mg capsule [HHSC]

Facility

$3.00

Service Code	NDC 68462040601
Hospital Charge Code	2500413
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

INDUCED ABORTION, BY DILATION AND CURETTAGE

Facility

$11,157.19

Service Code	CPT 59840
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$11,157.19
Rate for Payer: AlohaCare Medicaid	$1,568.64
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$11,157.19

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$14,685.70

Service Code	MSDRG 758
Min. Negotiated Rate	$14,685.70
Max. Negotiated Rate	$14,685.70
Rate for Payer: Hawaii Medical Service Association Commercial	$14,685.70

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$14,685.70

Service Code	MSDRG 757
Min. Negotiated Rate	$14,685.70
Max. Negotiated Rate	$14,685.70
Rate for Payer: Hawaii Medical Service Association Commercial	$14,685.70

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$14,685.70

Service Code	MSDRG 759
Min. Negotiated Rate	$14,685.70
Max. Negotiated Rate	$14,685.70
Rate for Payer: Hawaii Medical Service Association Commercial	$14,685.70

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$165,698.50

Service Code	MSDRG 854
Min. Negotiated Rate	$165,698.50
Max. Negotiated Rate	$165,698.50
Rate for Payer: Hawaii Medical Service Association Commercial	$165,698.50

Know your out-of-pocket cost for care.

All Charges