Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

IV CATHETER SHIELDED 22G

Facility

$11.00

Service Code	HCPCS C1751
Hospital Charge Code	8266443
Hospital Revenue Code	272
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 CATHETER SHIELDED 22G

Facility

$11.00

Service Code	HCPCS C1751
Hospital Charge Code	8266443
Hospital Revenue Code	272
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 CATHETER SHIELDED 24G

Facility

$14.00

Service Code	HCPCS C1751
Hospital Charge Code	8266342
Hospital Revenue Code	272
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$13.58
Rate for Payer: AlohaCare Medicaid	$7.00
Rate for Payer: AlohaCare Medicare	$7.00
Rate for Payer: Cash Price	$9.10
Rate for Payer: Devoted Health Medicare	$7.70
Rate for Payer: Hawaii Medical Service Association Medicare	$7.00
Rate for Payer: Hawaii Western Management Group Commercial	$13.30
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Humana Medicare	$7.00
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: Kaiser Permanente Medicaid	$7.14
Rate for Payer: Kaiser Permanente Medicare	$7.00
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: Ohana Health Plan Medicaid	$7.00
Rate for Payer: Ohana Health Plan Medicare	$7.00
Rate for Payer: UnitedHealthcare Medicare	$7.00
Rate for Payer: University Health Alliance Commercial	$10.20

IV CATHETER SHIELDED 24G

Facility

$14.00

Service Code	HCPCS C1751
Hospital Charge Code	8266342
Hospital Revenue Code	272
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$13.58
Rate for Payer: Cash Price	$9.10
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$13.58

ivermectin 3 mg tablet [HHSC]

Facility

$27.63

Service Code	HCPCS J4899
Hospital Charge Code	2501013
Hospital Revenue Code	250
Min. Negotiated Rate	$23.49
Max. Negotiated Rate	$26.80
Rate for Payer: Cash Price	$17.96
Rate for Payer: Health Management Network Commercial	$23.49
Rate for Payer: Kaiser Permanente Commercial	$24.87
Rate for Payer: MDX Hawaii PPO	$26.80

ivermectin 3 mg tablet [HHSC]

Facility

$27.63

Service Code	HCPCS J4899
Hospital Charge Code	2501013
Hospital Revenue Code	637
Min. Negotiated Rate	$13.81
Max. Negotiated Rate	$26.80
Rate for Payer: AlohaCare Medicaid	$13.81
Rate for Payer: AlohaCare Medicare	$13.81
Rate for Payer: Cash Price	$17.96
Rate for Payer: Devoted Health Medicare	$15.20
Rate for Payer: Hawaii Medical Service Association Medicare	$13.81
Rate for Payer: Hawaii Western Management Group Commercial	$26.25
Rate for Payer: Health Management Network Commercial	$23.49
Rate for Payer: Humana Medicare	$13.81
Rate for Payer: Kaiser Permanente Commercial	$24.87
Rate for Payer: Kaiser Permanente Medicaid	$14.09
Rate for Payer: Kaiser Permanente Medicare	$13.81
Rate for Payer: MDX Hawaii PPO	$26.80
Rate for Payer: Ohana Health Plan Medicaid	$13.81
Rate for Payer: Ohana Health Plan Medicare	$13.81
Rate for Payer: UnitedHealthcare Medicare	$13.81
Rate for Payer: University Health Alliance Commercial	$20.14

IV KCL 10 MEQ DEX5% .45NACL 1000ML

Facility

$26.00

Hospital Charge Code	8266642
Hospital Revenue Code	258
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

IV KCL 10 MEQ DEX5% .45NACL 1000ML

Facility

$26.00

Hospital Charge Code	8266642
Hospital Revenue Code	258
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

IV KCL 20 MEQ .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266512
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 KCL 20 MEQ .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266512
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 KCL 20MEQ DEX5% .45%NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266506
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 KCL 20MEQ DEX5% .45%NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266506
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 KCL 20 MEQ DEX 5% .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266643
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 KCL 20 MEQ DEX 5% .9% NACL 1000ML

Facility

$15.00

Hospital Charge Code	8266643
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 LACTATED RINGER 1000ML

Facility

$11.00

Hospital Charge Code	8266425
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 LACTATED RINGER 1000ML

Facility

$11.00

Hospital Charge Code	8266425
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

J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

Facility

$1,729.00

Service Code	HCPCS J7307
Hospital Charge Code	8041390
Hospital Revenue Code	250
Min. Negotiated Rate	$1,469.65
Max. Negotiated Rate	$1,677.13
Rate for Payer: Cash Price	$1,123.85
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: Kaiser Permanente Commercial	$1,556.10
Rate for Payer: MDX Hawaii PPO	$1,677.13

J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

Facility

$1,729.00

Service Code	HCPCS J7307
Hospital Charge Code	8041390
Hospital Revenue Code	250
Min. Negotiated Rate	$864.50
Max. Negotiated Rate	$1,677.13
Rate for Payer: AlohaCare Medicaid	$864.50
Rate for Payer: AlohaCare Medicare	$864.50
Rate for Payer: Cash Price	$1,123.85
Rate for Payer: Cash Price	$1,123.85
Rate for Payer: Devoted Health Medicare	$950.95
Rate for Payer: Hawaii Medical Service Association ABD	$1,214.63
Rate for Payer: Hawaii Medical Service Association Medicare	$864.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,214.63
Rate for Payer: Hawaii Western Management Group Commercial	$1,642.55
Rate for Payer: Health Management Network Commercial	$1,469.65
Rate for Payer: Humana Medicare	$864.50
Rate for Payer: Kaiser Permanente Commercial	$1,556.10
Rate for Payer: Kaiser Permanente Medicaid	$881.79
Rate for Payer: Kaiser Permanente Medicare	$864.50
Rate for Payer: MDX Hawaii PPO	$1,677.13
Rate for Payer: Ohana Health Plan Medicaid	$864.50
Rate for Payer: Ohana Health Plan Medicare	$864.50
Rate for Payer: UnitedHealthcare Medicaid	$1,037.40
Rate for Payer: UnitedHealthcare Medicare	$864.50
Rate for Payer: University Health Alliance Commercial	$1,260.27

JADA SYSTEM 2.0

Facility

$2,700.00

Hospital Charge Code	10039741
Hospital Revenue Code	272
Min. Negotiated Rate	$1,350.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: AlohaCare Medicaid	$1,350.00
Rate for Payer: AlohaCare Medicare	$1,350.00
Rate for Payer: Cash Price	$1,755.00
Rate for Payer: Devoted Health Medicare	$1,485.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,565.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Humana Medicare	$1,350.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: Kaiser Permanente Medicaid	$1,377.00
Rate for Payer: Kaiser Permanente Medicare	$1,350.00
Rate for Payer: MDX Hawaii PPO	$2,619.00
Rate for Payer: Ohana Health Plan Medicaid	$1,350.00
Rate for Payer: Ohana Health Plan Medicare	$1,350.00
Rate for Payer: UnitedHealthcare Medicare	$1,350.00
Rate for Payer: University Health Alliance Commercial	$1,968.03

JADA SYSTEM 2.0

Facility

$2,700.00

Hospital Charge Code	10039741
Hospital Revenue Code	272
Min. Negotiated Rate	$2,295.00
Max. Negotiated Rate	$2,619.00
Rate for Payer: Cash Price	$1,755.00
Rate for Payer: Health Management Network Commercial	$2,295.00
Rate for Payer: Kaiser Permanente Commercial	$2,430.00
Rate for Payer: MDX Hawaii PPO	$2,619.00

JAK2 Exon 12 Mutation Analysis

Facility

$1,360.00

Service Code	HCPCS 81279
Hospital Charge Code	12514691
Hospital Revenue Code	300
Min. Negotiated Rate	$111.12
Max. Negotiated Rate	$1,319.20
Rate for Payer: AlohaCare Medicaid	$680.00
Rate for Payer: AlohaCare Medicare	$680.00
Rate for Payer: Cash Price	$884.00
Rate for Payer: Cash Price	$884.00
Rate for Payer: Devoted Health Medicare	$748.00
Rate for Payer: Hawaii Medical Service Association ABD	$185.20
Rate for Payer: Hawaii Medical Service Association Commercial	$231.50
Rate for Payer: Hawaii Medical Service Association Medicare	$680.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$185.20
Rate for Payer: Hawaii Western Management Group Commercial	$185.20
Rate for Payer: Health Management Network Commercial	$1,156.00
Rate for Payer: Humana Medicare	$680.00
Rate for Payer: Kaiser Permanente Commercial	$1,224.00
Rate for Payer: Kaiser Permanente Medicaid	$693.60
Rate for Payer: Kaiser Permanente Medicare	$680.00
Rate for Payer: MDX Hawaii PPO	$1,319.20
Rate for Payer: Ohana Health Plan Medicaid	$680.00
Rate for Payer: Ohana Health Plan Medicare	$680.00
Rate for Payer: UnitedHealthcare Medicaid	$111.12
Rate for Payer: UnitedHealthcare Medicare	$680.00
Rate for Payer: University Health Alliance Commercial	$991.30

JAK2 Exon 12 Mutation Analysis

Facility

$1,360.00

Service Code	HCPCS 81279
Hospital Charge Code	12514691
Hospital Revenue Code	300
Min. Negotiated Rate	$1,156.00
Max. Negotiated Rate	$1,319.20
Rate for Payer: Cash Price	$884.00
Rate for Payer: Health Management Network Commercial	$1,156.00
Rate for Payer: Kaiser Permanente Commercial	$1,224.00
Rate for Payer: MDX Hawaii PPO	$1,319.20

.JAK2 Exon 12 Mutations FSI

Facility

$514.00

Service Code	HCPCS 81279
Hospital Charge Code	10593921
Hospital Revenue Code	310
Min. Negotiated Rate	$111.12
Max. Negotiated Rate	$498.58
Rate for Payer: AlohaCare Medicaid	$257.00
Rate for Payer: AlohaCare Medicare	$257.00
Rate for Payer: Cash Price	$334.10
Rate for Payer: Cash Price	$334.10
Rate for Payer: Devoted Health Medicare	$282.70
Rate for Payer: Hawaii Medical Service Association ABD	$185.20
Rate for Payer: Hawaii Medical Service Association Commercial	$231.50
Rate for Payer: Hawaii Medical Service Association Medicare	$257.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$185.20
Rate for Payer: Hawaii Western Management Group Commercial	$185.20
Rate for Payer: Health Management Network Commercial	$436.90
Rate for Payer: Humana Medicare	$257.00
Rate for Payer: Kaiser Permanente Commercial	$462.60
Rate for Payer: Kaiser Permanente Medicaid	$262.14
Rate for Payer: Kaiser Permanente Medicare	$257.00
Rate for Payer: MDX Hawaii PPO	$498.58
Rate for Payer: Ohana Health Plan Medicaid	$257.00
Rate for Payer: Ohana Health Plan Medicare	$257.00
Rate for Payer: UnitedHealthcare Medicaid	$111.12
Rate for Payer: UnitedHealthcare Medicare	$257.00
Rate for Payer: University Health Alliance Commercial	$374.65

.JAK2 Exon 12 Mutations FSI

Facility

$514.00

Service Code	HCPCS 81279
Hospital Charge Code	10593921
Hospital Revenue Code	310
Min. Negotiated Rate	$436.90
Max. Negotiated Rate	$498.58
Rate for Payer: Cash Price	$334.10
Rate for Payer: Health Management Network Commercial	$436.90
Rate for Payer: Kaiser Permanente Commercial	$462.60
Rate for Payer: MDX Hawaii PPO	$498.58

JAK2 Mut Rfx CALR MPL FSI

Facility

$520.00

Service Code	HCPCS 81270
Hospital Charge Code	10596933
Hospital Revenue Code	310
Min. Negotiated Rate	$49.73
Max. Negotiated Rate	$504.40
Rate for Payer: AlohaCare Medicaid	$260.00
Rate for Payer: AlohaCare Medicare	$260.00
Rate for Payer: Cash Price	$338.00
Rate for Payer: Cash Price	$338.00
Rate for Payer: Devoted Health Medicare	$286.00
Rate for Payer: Hawaii Medical Service Association ABD	$122.70
Rate for Payer: Hawaii Medical Service Association Commercial	$114.58
Rate for Payer: Hawaii Medical Service Association Medicare	$260.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.70
Rate for Payer: Hawaii Western Management Group Commercial	$91.66
Rate for Payer: Health Management Network Commercial	$442.00
Rate for Payer: Humana Medicare	$260.00
Rate for Payer: Kaiser Permanente Commercial	$468.00
Rate for Payer: Kaiser Permanente Medicaid	$265.20
Rate for Payer: Kaiser Permanente Medicare	$260.00
Rate for Payer: MDX Hawaii PPO	$504.40
Rate for Payer: Ohana Health Plan Medicaid	$260.00
Rate for Payer: Ohana Health Plan Medicare	$260.00
Rate for Payer: UnitedHealthcare Medicaid	$49.73
Rate for Payer: UnitedHealthcare Medicare	$260.00
Rate for Payer: University Health Alliance Commercial	$230.79

Know your out-of-pocket cost for care.

All Charges