Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

isopropyl alcohol 70% 473ml [HHSC]

Facility

$3.00

Service Code	NDC 00574006716
Hospital Charge Code	2500430
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

isopropyl alcohol 70% 473ml [HHSC]

Facility

$3.00

Service Code	NDC 46122033043
Hospital Charge Code	2500430
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

isopropyl alcohol 70% 473ml [HHSC]

Facility

$3.00

Service Code	NDC 46122033043
Hospital Charge Code	2500430
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

isopropyl alcohol 70% 473ml [HHSC]

Facility

$3.00

Service Code	NDC 00574006716
Hospital Charge Code	2500430
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

isosorbide dinitrate 10 mg tablet [HHSC]

Facility

$6.95

Service Code	NDC 68084008201
Hospital Charge Code	2500431
Hospital Revenue Code	250
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$6.74
Rate for Payer: AlohaCare Medicaid	$3.48
Rate for Payer: AlohaCare Medicare	$3.48
Rate for Payer: Cash Price	$4.52
Rate for Payer: Devoted Health Medicare	$3.82
Rate for Payer: Hawaii Medical Service Association Medicare	$3.48
Rate for Payer: Hawaii Western Management Group Commercial	$6.60
Rate for Payer: Health Management Network Commercial	$5.91
Rate for Payer: Humana Medicare	$3.48
Rate for Payer: Kaiser Permanente Commercial	$6.25
Rate for Payer: Kaiser Permanente Medicaid	$3.54
Rate for Payer: Kaiser Permanente Medicare	$3.48
Rate for Payer: MDX Hawaii PPO	$6.74
Rate for Payer: Ohana Health Plan Medicaid	$3.48
Rate for Payer: Ohana Health Plan Medicare	$3.48
Rate for Payer: UnitedHealthcare Medicaid	$4.17
Rate for Payer: UnitedHealthcare Medicare	$3.48
Rate for Payer: University Health Alliance Commercial	$5.07

isosorbide dinitrate 10 mg tablet [HHSC]

Facility

$6.95

Service Code	NDC 68084008201
Hospital Charge Code	2500431
Hospital Revenue Code	250
Min. Negotiated Rate	$5.91
Max. Negotiated Rate	$6.74
Rate for Payer: Cash Price	$4.52
Rate for Payer: Health Management Network Commercial	$5.91
Rate for Payer: Kaiser Permanente Commercial	$6.25
Rate for Payer: MDX Hawaii PPO	$6.74

isosorbide dinitrate 20 mg tablet [HHSC]

Facility

$7.51

Service Code	NDC 68084008301
Hospital Charge Code	2500432
Hospital Revenue Code	250
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$7.28
Rate for Payer: AlohaCare Medicaid	$3.75
Rate for Payer: AlohaCare Medicare	$3.75
Rate for Payer: Cash Price	$4.88
Rate for Payer: Devoted Health Medicare	$4.13
Rate for Payer: Hawaii Medical Service Association Medicare	$3.75
Rate for Payer: Hawaii Western Management Group Commercial	$7.13
Rate for Payer: Health Management Network Commercial	$6.38
Rate for Payer: Humana Medicare	$3.75
Rate for Payer: Kaiser Permanente Commercial	$6.76
Rate for Payer: Kaiser Permanente Medicaid	$3.83
Rate for Payer: Kaiser Permanente Medicare	$3.75
Rate for Payer: MDX Hawaii PPO	$7.28
Rate for Payer: Ohana Health Plan Medicaid	$3.75
Rate for Payer: Ohana Health Plan Medicare	$3.75
Rate for Payer: UnitedHealthcare Medicaid	$4.51
Rate for Payer: UnitedHealthcare Medicare	$3.75
Rate for Payer: University Health Alliance Commercial	$5.47

isosorbide dinitrate 20 mg tablet [HHSC]

Facility

$6.63

Service Code	NDC 68001037500
Hospital Charge Code	2500432
Hospital Revenue Code	250
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$6.43
Rate for Payer: AlohaCare Medicaid	$3.31
Rate for Payer: AlohaCare Medicare	$3.31
Rate for Payer: Cash Price	$4.31
Rate for Payer: Devoted Health Medicare	$3.65
Rate for Payer: Hawaii Medical Service Association Medicare	$3.31
Rate for Payer: Hawaii Western Management Group Commercial	$6.30
Rate for Payer: Health Management Network Commercial	$5.64
Rate for Payer: Humana Medicare	$3.31
Rate for Payer: Kaiser Permanente Commercial	$5.97
Rate for Payer: Kaiser Permanente Medicaid	$3.38
Rate for Payer: Kaiser Permanente Medicare	$3.31
Rate for Payer: MDX Hawaii PPO	$6.43
Rate for Payer: Ohana Health Plan Medicaid	$3.31
Rate for Payer: Ohana Health Plan Medicare	$3.31
Rate for Payer: UnitedHealthcare Medicaid	$3.98
Rate for Payer: UnitedHealthcare Medicare	$3.31
Rate for Payer: University Health Alliance Commercial	$4.83

isosorbide dinitrate 20 mg tablet [HHSC]

Facility

$6.63

Service Code	NDC 68001037500
Hospital Charge Code	2500432
Hospital Revenue Code	250
Min. Negotiated Rate	$5.64
Max. Negotiated Rate	$6.43
Rate for Payer: Cash Price	$4.31
Rate for Payer: Health Management Network Commercial	$5.64
Rate for Payer: Kaiser Permanente Commercial	$5.97
Rate for Payer: MDX Hawaii PPO	$6.43

isosorbide dinitrate 20 mg tablet [HHSC]

Facility

$7.51

Service Code	NDC 68084008301
Hospital Charge Code	2500432
Hospital Revenue Code	250
Min. Negotiated Rate	$6.38
Max. Negotiated Rate	$7.28
Rate for Payer: Cash Price	$4.88
Rate for Payer: Health Management Network Commercial	$6.38
Rate for Payer: Kaiser Permanente Commercial	$6.76
Rate for Payer: MDX Hawaii PPO	$7.28

isosulfan blue 1% 5ml vial [HHSC]

Facility

$2,745.15

Service Code	NDC 67457022005
Hospital Charge Code	2500434
Hospital Revenue Code	250
Min. Negotiated Rate	$1,372.58
Max. Negotiated Rate	$2,662.80
Rate for Payer: AlohaCare Medicaid	$1,372.58
Rate for Payer: AlohaCare Medicare	$1,372.58
Rate for Payer: Cash Price	$1,784.35
Rate for Payer: Devoted Health Medicare	$1,509.83
Rate for Payer: Hawaii Medical Service Association Medicare	$1,372.58
Rate for Payer: Hawaii Western Management Group Commercial	$2,607.89
Rate for Payer: Health Management Network Commercial	$2,333.38
Rate for Payer: Humana Medicare	$1,372.58
Rate for Payer: Kaiser Permanente Commercial	$2,470.64
Rate for Payer: Kaiser Permanente Medicaid	$1,400.03
Rate for Payer: Kaiser Permanente Medicare	$1,372.58
Rate for Payer: MDX Hawaii PPO	$2,662.80
Rate for Payer: Ohana Health Plan Medicaid	$1,372.58
Rate for Payer: Ohana Health Plan Medicare	$1,372.58
Rate for Payer: UnitedHealthcare Medicaid	$1,647.09
Rate for Payer: UnitedHealthcare Medicare	$1,372.58
Rate for Payer: University Health Alliance Commercial	$2,000.94

isosulfan blue 1% 5ml vial [HHSC]

Facility

$2,745.15

Service Code	NDC 67457022005
Hospital Charge Code	2500434
Hospital Revenue Code	250
Min. Negotiated Rate	$2,333.38
Max. Negotiated Rate	$2,662.80
Rate for Payer: Cash Price	$1,784.35
Rate for Payer: Health Management Network Commercial	$2,333.38
Rate for Payer: Kaiser Permanente Commercial	$2,470.64
Rate for Payer: MDX Hawaii PPO	$2,662.80

IV 10% DEXTROSE 500ML

Facility

$15.00

Hospital Charge Code	8266623
Hospital Revenue Code	258
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

IV 10% DEXTROSE 500ML

Facility

$15.00

Hospital Charge Code	8266623
Hospital Revenue Code	258
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$7.50
Rate for Payer: Cash Price	$9.75
Rate for Payer: Devoted Health Medicare	$8.25
Rate for Payer: Hawaii Medical Service Association Medicare	$7.50
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$7.50
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$7.50
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$7.50
Rate for Payer: Ohana Health Plan Medicare	$7.50
Rate for Payer: UnitedHealthcare Medicare	$7.50
Rate for Payer: University Health Alliance Commercial	$10.93

IV 20MEQ POTASSIUM .45% NS 1000ML

Facility

$39.00

Hospital Charge Code	8266286
Hospital Revenue Code	258
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$37.83
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$19.50
Rate for Payer: Cash Price	$25.35
Rate for Payer: Devoted Health Medicare	$21.45
Rate for Payer: Hawaii Medical Service Association Medicare	$19.50
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Humana Medicare	$19.50
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicare	$19.50
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$19.50
Rate for Payer: Ohana Health Plan Medicare	$19.50
Rate for Payer: UnitedHealthcare Medicare	$19.50
Rate for Payer: University Health Alliance Commercial	$28.43

IV 20MEQ POTASSIUM .45% NS 1000ML

Facility

$39.00

Hospital Charge Code	8266286
Hospital Revenue Code	258
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$25.35
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83

IV .45% NACL 1000ML

Facility

$11.00

Hospital Charge Code	8266499
Hospital Revenue Code	258
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$7.15
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

IV .45% NACL 1000ML

Facility

$11.00

Hospital Charge Code	8266499
Hospital Revenue Code	258
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$5.50
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5.50
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$5.50
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$5.50
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$5.50
Rate for Payer: Ohana Health Plan Medicare	$5.50
Rate for Payer: UnitedHealthcare Medicare	$5.50
Rate for Payer: University Health Alliance Commercial	$8.02

IV 5% DEX .20% NACL 500ML

Facility

$10.00

Hospital Charge Code	8266624
Hospital Revenue Code	258
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

IV 5% DEX .20% NACL 500ML

Facility

$10.00

Hospital Charge Code	8266624
Hospital Revenue Code	258
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

IV 5% DEX .45% NACL 1000ML

Facility

$12.00

Hospital Charge Code	8266504
Hospital Revenue Code	258
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

IV 5% DEX .45% NACL 1000ML

Facility

$12.00

Hospital Charge Code	8266504
Hospital Revenue Code	258
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

IV 5% DEX .9% NACL 1000ML

Facility

$23.00

Hospital Charge Code	8266505
Hospital Revenue Code	258
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

IV 5% DEX .9% NACL 1000ML

Facility

$23.00

Hospital Charge Code	8266505
Hospital Revenue Code	258
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$11.50
Rate for Payer: Cash Price	$14.95
Rate for Payer: Devoted Health Medicare	$12.65
Rate for Payer: Hawaii Medical Service Association Medicare	$11.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$11.50
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$11.50
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$11.50
Rate for Payer: Ohana Health Plan Medicare	$11.50
Rate for Payer: UnitedHealthcare Medicare	$11.50
Rate for Payer: University Health Alliance Commercial	$16.76

IV 5% DEXROSE PARTIAL FILL 100ML

Facility

$10.00

Hospital Charge Code	8266503
Hospital Revenue Code	258
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

Know your out-of-pocket cost for care.

All Charges