Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

LORazepam 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687063801
Hospital Charge Code	2500499
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

LORazepam 2 mg/1ml vial [HHSC]

Facility

$21.76

Service Code	HCPCS J2060
Hospital Charge Code	2500501
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$21.11
Rate for Payer: AlohaCare Medicaid	$10.88
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicaid	$6.34
Rate for Payer: AlohaCare Medicare	$2.50
Rate for Payer: AlohaCare Medicare	$6.34
Rate for Payer: AlohaCare Medicare	$10.88
Rate for Payer: Cash Price	$8.24
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$8.24
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$14.14
Rate for Payer: Cash Price	$14.14
Rate for Payer: Devoted Health Medicare	$2.75
Rate for Payer: Devoted Health Medicare	$11.97
Rate for Payer: Devoted Health Medicare	$6.97
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Medicare	$10.88
Rate for Payer: Hawaii Medical Service Association Medicare	$2.50
Rate for Payer: Hawaii Medical Service Association Medicare	$6.34
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Hawaii Western Management Group Commercial	$20.67
Rate for Payer: Health Management Network Commercial	$10.78
Rate for Payer: Health Management Network Commercial	$18.50
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$10.88
Rate for Payer: Humana Medicare	$6.34
Rate for Payer: Humana Medicare	$2.50
Rate for Payer: Kaiser Permanente Commercial	$19.58
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Commercial	$11.41
Rate for Payer: Kaiser Permanente Medicaid	$11.10
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicaid	$6.47
Rate for Payer: Kaiser Permanente Medicare	$10.88
Rate for Payer: Kaiser Permanente Medicare	$6.34
Rate for Payer: Kaiser Permanente Medicare	$2.50
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: MDX Hawaii PPO	$12.30
Rate for Payer: MDX Hawaii PPO	$21.11
Rate for Payer: Ohana Health Plan Medicaid	$10.88
Rate for Payer: Ohana Health Plan Medicaid	$2.50
Rate for Payer: Ohana Health Plan Medicaid	$6.34
Rate for Payer: Ohana Health Plan Medicare	$2.50
Rate for Payer: Ohana Health Plan Medicare	$6.34
Rate for Payer: Ohana Health Plan Medicare	$10.88
Rate for Payer: UnitedHealthcare Medicaid	$7.61
Rate for Payer: UnitedHealthcare Medicaid	$13.06
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicare	$6.34
Rate for Payer: UnitedHealthcare Medicare	$2.50
Rate for Payer: UnitedHealthcare Medicare	$10.88
Rate for Payer: University Health Alliance Commercial	$3.64
Rate for Payer: University Health Alliance Commercial	$15.86
Rate for Payer: University Health Alliance Commercial	$9.24

LORazepam 2 mg/1ml vial [HHSC]

Facility

$21.76

Service Code	HCPCS J2060
Hospital Charge Code	2500501
Hospital Revenue Code	250
Min. Negotiated Rate	$18.50
Max. Negotiated Rate	$21.11
Rate for Payer: Cash Price	$14.14
Rate for Payer: Cash Price	$8.24
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$10.78
Rate for Payer: Health Management Network Commercial	$18.50
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Commercial	$11.41
Rate for Payer: Kaiser Permanente Commercial	$19.58
Rate for Payer: MDX Hawaii PPO	$21.11
Rate for Payer: MDX Hawaii PPO	$12.30
Rate for Payer: MDX Hawaii PPO	$4.85

losartan 25 mg tablet [HHSC]

Facility

$9.36

Service Code	NDC 65862020190
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$6.08
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: Kaiser Permanente Commercial	$8.42
Rate for Payer: MDX Hawaii PPO	$9.08

losartan 25 mg tablet [HHSC]

Facility

$9.33

Service Code	NDC 68084034601
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$9.05
Rate for Payer: AlohaCare Medicaid	$4.67
Rate for Payer: AlohaCare Medicare	$4.67
Rate for Payer: Cash Price	$6.06
Rate for Payer: Devoted Health Medicare	$5.13
Rate for Payer: Hawaii Medical Service Association Medicare	$4.67
Rate for Payer: Hawaii Western Management Group Commercial	$8.86
Rate for Payer: Health Management Network Commercial	$7.93
Rate for Payer: Humana Medicare	$4.67
Rate for Payer: Kaiser Permanente Commercial	$8.40
Rate for Payer: Kaiser Permanente Medicaid	$4.76
Rate for Payer: Kaiser Permanente Medicare	$4.67
Rate for Payer: MDX Hawaii PPO	$9.05
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.67
Rate for Payer: UnitedHealthcare Medicaid	$5.60
Rate for Payer: UnitedHealthcare Medicare	$4.67
Rate for Payer: University Health Alliance Commercial	$6.80

losartan 25 mg tablet [HHSC]

Facility

$9.33

Service Code	NDC 68084034601
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$7.93
Max. Negotiated Rate	$9.05
Rate for Payer: Cash Price	$6.06
Rate for Payer: Health Management Network Commercial	$7.93
Rate for Payer: Kaiser Permanente Commercial	$8.40
Rate for Payer: MDX Hawaii PPO	$9.05

losartan 25 mg tablet [HHSC]

Facility

$9.36

Service Code	NDC 65862020190
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.08
Rate for Payer: AlohaCare Medicaid	$4.68
Rate for Payer: AlohaCare Medicare	$4.68
Rate for Payer: Cash Price	$6.08
Rate for Payer: Devoted Health Medicare	$5.15
Rate for Payer: Hawaii Medical Service Association Medicare	$4.68
Rate for Payer: Hawaii Western Management Group Commercial	$8.89
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: Humana Medicare	$4.68
Rate for Payer: Kaiser Permanente Commercial	$8.42
Rate for Payer: Kaiser Permanente Medicaid	$4.77
Rate for Payer: Kaiser Permanente Medicare	$4.68
Rate for Payer: MDX Hawaii PPO	$9.08
Rate for Payer: Ohana Health Plan Medicaid	$4.68
Rate for Payer: Ohana Health Plan Medicare	$4.68
Rate for Payer: UnitedHealthcare Medicaid	$5.62
Rate for Payer: UnitedHealthcare Medicare	$4.68
Rate for Payer: University Health Alliance Commercial	$6.82

losartan 50 mg tablet [HHSC]

Facility

$12.58

Service Code	NDC 68180037703
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$12.20
Rate for Payer: AlohaCare Medicaid	$6.29
Rate for Payer: AlohaCare Medicare	$6.29
Rate for Payer: Cash Price	$8.18
Rate for Payer: Devoted Health Medicare	$6.92
Rate for Payer: Hawaii Medical Service Association Medicare	$6.29
Rate for Payer: Hawaii Western Management Group Commercial	$11.95
Rate for Payer: Health Management Network Commercial	$10.69
Rate for Payer: Humana Medicare	$6.29
Rate for Payer: Kaiser Permanente Commercial	$11.32
Rate for Payer: Kaiser Permanente Medicaid	$6.42
Rate for Payer: Kaiser Permanente Medicare	$6.29
Rate for Payer: MDX Hawaii PPO	$12.20
Rate for Payer: Ohana Health Plan Medicaid	$6.29
Rate for Payer: Ohana Health Plan Medicare	$6.29
Rate for Payer: UnitedHealthcare Medicaid	$7.55
Rate for Payer: UnitedHealthcare Medicare	$6.29
Rate for Payer: University Health Alliance Commercial	$9.17

losartan 50 mg tablet [HHSC]

Facility

$12.51

Service Code	NDC 68084034701
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$12.13
Rate for Payer: AlohaCare Medicaid	$6.25
Rate for Payer: AlohaCare Medicare	$6.25
Rate for Payer: Cash Price	$8.13
Rate for Payer: Devoted Health Medicare	$6.88
Rate for Payer: Hawaii Medical Service Association Medicare	$6.25
Rate for Payer: Hawaii Western Management Group Commercial	$11.88
Rate for Payer: Health Management Network Commercial	$10.63
Rate for Payer: Humana Medicare	$6.25
Rate for Payer: Kaiser Permanente Commercial	$11.26
Rate for Payer: Kaiser Permanente Medicaid	$6.38
Rate for Payer: Kaiser Permanente Medicare	$6.25
Rate for Payer: MDX Hawaii PPO	$12.13
Rate for Payer: Ohana Health Plan Medicaid	$6.25
Rate for Payer: Ohana Health Plan Medicare	$6.25
Rate for Payer: UnitedHealthcare Medicaid	$7.51
Rate for Payer: UnitedHealthcare Medicare	$6.25
Rate for Payer: University Health Alliance Commercial	$9.12

losartan 50 mg tablet [HHSC]

Facility

$24.75

Service Code	NDC 00006095254
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$21.04
Max. Negotiated Rate	$24.01
Rate for Payer: Cash Price	$16.09
Rate for Payer: Health Management Network Commercial	$21.04
Rate for Payer: Kaiser Permanente Commercial	$22.27
Rate for Payer: MDX Hawaii PPO	$24.01

losartan 50 mg tablet [HHSC]

Facility

$24.75

Service Code	NDC 00006095254
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$24.01
Rate for Payer: AlohaCare Medicaid	$12.38
Rate for Payer: AlohaCare Medicare	$12.38
Rate for Payer: Cash Price	$16.09
Rate for Payer: Devoted Health Medicare	$13.61
Rate for Payer: Hawaii Medical Service Association Medicare	$12.38
Rate for Payer: Hawaii Western Management Group Commercial	$23.51
Rate for Payer: Health Management Network Commercial	$21.04
Rate for Payer: Humana Medicare	$12.38
Rate for Payer: Kaiser Permanente Commercial	$22.27
Rate for Payer: Kaiser Permanente Medicaid	$12.62
Rate for Payer: Kaiser Permanente Medicare	$12.38
Rate for Payer: MDX Hawaii PPO	$24.01
Rate for Payer: Ohana Health Plan Medicaid	$12.38
Rate for Payer: Ohana Health Plan Medicare	$12.38
Rate for Payer: UnitedHealthcare Medicaid	$14.85
Rate for Payer: UnitedHealthcare Medicare	$12.38
Rate for Payer: University Health Alliance Commercial	$18.04

losartan 50 mg tablet [HHSC]

Facility

$12.51

Service Code	NDC 68084034701
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$12.13
Rate for Payer: Cash Price	$8.13
Rate for Payer: Health Management Network Commercial	$10.63
Rate for Payer: Kaiser Permanente Commercial	$11.26
Rate for Payer: MDX Hawaii PPO	$12.13

losartan 50 mg tablet [HHSC]

Facility

$12.58

Service Code	NDC 68180037703
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$10.69
Max. Negotiated Rate	$12.20
Rate for Payer: Cash Price	$8.18
Rate for Payer: Health Management Network Commercial	$10.69
Rate for Payer: Kaiser Permanente Commercial	$11.32
Rate for Payer: MDX Hawaii PPO	$12.20

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$58,895.76

Service Code	MSDRG 493
Min. Negotiated Rate	$58,895.76
Max. Negotiated Rate	$58,895.76
Rate for Payer: Hawaii Medical Service Association Commercial	$58,895.76

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$58,895.76

Service Code	MSDRG 492
Min. Negotiated Rate	$58,895.76
Max. Negotiated Rate	$58,895.76
Rate for Payer: Hawaii Medical Service Association Commercial	$58,895.76

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$34,776.54

Service Code	MSDRG 494
Min. Negotiated Rate	$34,776.54
Max. Negotiated Rate	$34,776.54
Rate for Payer: Hawaii Medical Service Association Commercial	$34,776.54

LOW PROFILE SCREW, 2.0 X 10MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987707
Hospital Revenue Code	278
Min. Negotiated Rate	$72.50
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 10MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987707
Hospital Revenue Code	278
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 11MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987705
Hospital Revenue Code	278
Min. Negotiated Rate	$72.50
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 11MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987705
Hospital Revenue Code	278
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 12MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987708
Hospital Revenue Code	278
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 12MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987708
Hospital Revenue Code	278
Min. Negotiated Rate	$72.50
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 13MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987709
Hospital Revenue Code	278
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 13MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987709
Hospital Revenue Code	278
Min. Negotiated Rate	$72.50
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$81.20

LOW PROFILE SCREW, 2.0 X 14MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12987714
Hospital Revenue Code	278
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$101.50
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$81.20

Know your out-of-pocket cost for care.

All Charges