Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

LOW PROFILE SCREW, 2.0 X 38MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12991227
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 38MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12991227
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 40MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12991225
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 40MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12991225
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 7MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989507
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 7MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989507
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 8MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989508
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 8MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989508
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 9MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989509
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 9MM, CORTICAL

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989509
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, 2.4MM X 13MM CORTEX

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989535
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, 2.4MM X 13MM CORTEX

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989535
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, 2.4MM X 36MM CORTEX

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989536
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, 2.4MM X 36MM CORTEX

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989536
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, 2.4MM X 38MM CORTEX

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989537
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, 2.4MM X 38MM CORTEX

Facility

$145.00

Service Code	HCPCS C1713
Hospital Charge Code	12989537
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

LTD Color Doppler

Facility

$511.00

Service Code	HCPCS 93325
Hospital Charge Code	12216457
Hospital Revenue Code	483
Min. Negotiated Rate	$434.35
Max. Negotiated Rate	$495.67
Rate for Payer: Cash Price	$332.15
Rate for Payer: Health Management Network Commercial	$434.35
Rate for Payer: Kaiser Permanente Commercial	$459.90
Rate for Payer: MDX Hawaii PPO	$495.67

LTD Color Doppler

Facility

$511.00

Service Code	HCPCS 93325
Hospital Charge Code	12216457
Hospital Revenue Code	483
Min. Negotiated Rate	$40.70
Max. Negotiated Rate	$495.67
Rate for Payer: AlohaCare Medicaid	$255.50
Rate for Payer: AlohaCare Medicare	$255.50
Rate for Payer: Cash Price	$332.15
Rate for Payer: Cash Price	$332.15
Rate for Payer: Devoted Health Medicare	$281.05
Rate for Payer: Hawaii Medical Service Association ABD	$96.84
Rate for Payer: Hawaii Medical Service Association Medicare	$255.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.70
Rate for Payer: Hawaii Western Management Group Commercial	$485.45
Rate for Payer: Health Management Network Commercial	$434.35
Rate for Payer: Humana Medicare	$255.50
Rate for Payer: Kaiser Permanente Commercial	$459.90
Rate for Payer: Kaiser Permanente Medicaid	$260.61
Rate for Payer: Kaiser Permanente Medicare	$255.50
Rate for Payer: MDX Hawaii PPO	$495.67
Rate for Payer: Ohana Health Plan Medicaid	$255.50
Rate for Payer: Ohana Health Plan Medicare	$255.50
Rate for Payer: UnitedHealthcare Medicaid	$96.84
Rate for Payer: UnitedHealthcare Medicare	$255.50
Rate for Payer: University Health Alliance Commercial	$372.47

LTD Spectral Doppler

Facility

$439.00

Service Code	HCPCS 93321
Hospital Charge Code	12205326
Hospital Revenue Code	483
Min. Negotiated Rate	$373.15
Max. Negotiated Rate	$425.83
Rate for Payer: Cash Price	$285.35
Rate for Payer: Health Management Network Commercial	$373.15
Rate for Payer: Kaiser Permanente Commercial	$395.10
Rate for Payer: MDX Hawaii PPO	$425.83

LTD Spectral Doppler

Facility

$439.00

Service Code	HCPCS 93321
Hospital Charge Code	12205326
Hospital Revenue Code	483
Min. Negotiated Rate	$37.31
Max. Negotiated Rate	$425.83
Rate for Payer: AlohaCare Medicaid	$219.50
Rate for Payer: AlohaCare Medicare	$219.50
Rate for Payer: Cash Price	$285.35
Rate for Payer: Cash Price	$285.35
Rate for Payer: Devoted Health Medicare	$241.45
Rate for Payer: Hawaii Medical Service Association ABD	$37.31
Rate for Payer: Hawaii Medical Service Association Medicare	$219.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39.18
Rate for Payer: Hawaii Western Management Group Commercial	$417.05
Rate for Payer: Health Management Network Commercial	$373.15
Rate for Payer: Humana Medicare	$219.50
Rate for Payer: Kaiser Permanente Commercial	$395.10
Rate for Payer: Kaiser Permanente Medicaid	$223.89
Rate for Payer: Kaiser Permanente Medicare	$219.50
Rate for Payer: MDX Hawaii PPO	$425.83
Rate for Payer: Ohana Health Plan Medicaid	$219.50
Rate for Payer: Ohana Health Plan Medicare	$219.50
Rate for Payer: UnitedHealthcare Medicaid	$37.31
Rate for Payer: UnitedHealthcare Medicare	$219.50
Rate for Payer: University Health Alliance Commercial	$319.99

lubriderm lotion 177ml [HHSC]

Facility

$14.40

Service Code	NDC 52800048816
Hospital Charge Code	2500282
Hospital Revenue Code	250
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$13.97
Rate for Payer: Cash Price	$9.36
Rate for Payer: Health Management Network Commercial	$12.24
Rate for Payer: Kaiser Permanente Commercial	$12.96
Rate for Payer: MDX Hawaii PPO	$13.97

lubriderm lotion 177ml [HHSC]

Facility

$14.40

Service Code	NDC 52800048816
Hospital Charge Code	2500282
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$13.97
Rate for Payer: AlohaCare Medicaid	$7.20
Rate for Payer: AlohaCare Medicare	$7.20
Rate for Payer: Cash Price	$9.36
Rate for Payer: Devoted Health Medicare	$7.92
Rate for Payer: Hawaii Medical Service Association Medicare	$7.20
Rate for Payer: Hawaii Western Management Group Commercial	$13.68
Rate for Payer: Health Management Network Commercial	$12.24
Rate for Payer: Humana Medicare	$7.20
Rate for Payer: Kaiser Permanente Commercial	$12.96
Rate for Payer: Kaiser Permanente Medicaid	$7.34
Rate for Payer: Kaiser Permanente Medicare	$7.20
Rate for Payer: MDX Hawaii PPO	$13.97
Rate for Payer: Ohana Health Plan Medicaid	$7.20
Rate for Payer: Ohana Health Plan Medicare	$7.20
Rate for Payer: UnitedHealthcare Medicaid	$8.64
Rate for Payer: UnitedHealthcare Medicare	$7.20
Rate for Payer: University Health Alliance Commercial	$10.50

lubriderm lotion 177ml [HHSC]

Facility

$14.12

Service Code	NDC 52800048826
Hospital Charge Code	2500282
Hospital Revenue Code	250
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$13.70
Rate for Payer: Cash Price	$9.18
Rate for Payer: Health Management Network Commercial	$12.00
Rate for Payer: Kaiser Permanente Commercial	$12.71
Rate for Payer: MDX Hawaii PPO	$13.70

lubriderm lotion 177ml [HHSC]

Facility

$14.12

Service Code	NDC 52800048826
Hospital Charge Code	2500282
Hospital Revenue Code	250
Min. Negotiated Rate	$7.06
Max. Negotiated Rate	$13.70
Rate for Payer: AlohaCare Medicaid	$7.06
Rate for Payer: AlohaCare Medicare	$7.06
Rate for Payer: Cash Price	$9.18
Rate for Payer: Devoted Health Medicare	$7.77
Rate for Payer: Hawaii Medical Service Association Medicare	$7.06
Rate for Payer: Hawaii Western Management Group Commercial	$13.41
Rate for Payer: Health Management Network Commercial	$12.00
Rate for Payer: Humana Medicare	$7.06
Rate for Payer: Kaiser Permanente Commercial	$12.71
Rate for Payer: Kaiser Permanente Medicaid	$7.20
Rate for Payer: Kaiser Permanente Medicare	$7.06
Rate for Payer: MDX Hawaii PPO	$13.70
Rate for Payer: Ohana Health Plan Medicaid	$7.06
Rate for Payer: Ohana Health Plan Medicare	$7.06
Rate for Payer: UnitedHealthcare Medicaid	$8.47
Rate for Payer: UnitedHealthcare Medicare	$7.06
Rate for Payer: University Health Alliance Commercial	$10.29

Lumbar Tray at Bedside

Facility

$1,136.00

Service Code	HCPCS 62270
Hospital Charge Code	1909307
Hospital Revenue Code	361
Min. Negotiated Rate	$965.60
Max. Negotiated Rate	$1,101.92
Rate for Payer: Cash Price	$738.40
Rate for Payer: Health Management Network Commercial	$965.60
Rate for Payer: Kaiser Permanente Commercial	$1,022.40
Rate for Payer: MDX Hawaii PPO	$1,101.92

Know your out-of-pocket cost for care.

All Charges