Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

MAX BREATHING CAPACITY CHARGE

Facility

$346.00

Service Code	HCPCS 94200
Hospital Charge Code	8243391
Hospital Revenue Code	460
Min. Negotiated Rate	$294.10
Max. Negotiated Rate	$335.62
Rate for Payer: Cash Price	$224.90
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: MDX Hawaii PPO	$335.62

MDI TREATMENT CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8243392
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$2,389.00
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
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	$214.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$311.97

MDI TREATMENT CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8243392
Hospital Revenue Code	410
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

measles-mump-rubel (PF) vacc 0.5 mL [HHSC]

Facility

$486.82

Service Code	HCPCS 90707
Hospital Charge Code	2501211
Hospital Revenue Code	250
Min. Negotiated Rate	$413.80
Max. Negotiated Rate	$472.22
Rate for Payer: Cash Price	$316.43
Rate for Payer: Health Management Network Commercial	$413.80
Rate for Payer: Kaiser Permanente Commercial	$438.14
Rate for Payer: MDX Hawaii PPO	$472.22

measles-mump-rubel (PF) vacc 0.5 mL [HHSC]

Facility

$486.82

Service Code	HCPCS 90707
Hospital Charge Code	2501211
Hospital Revenue Code	636
Min. Negotiated Rate	$102.41
Max. Negotiated Rate	$472.22
Rate for Payer: AlohaCare Medicaid	$243.41
Rate for Payer: AlohaCare Medicare	$243.41
Rate for Payer: Cash Price	$316.43
Rate for Payer: Cash Price	$316.43
Rate for Payer: Devoted Health Medicare	$267.75
Rate for Payer: Hawaii Medical Service Association ABD	$102.41
Rate for Payer: Hawaii Medical Service Association Medicare	$243.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$102.41
Rate for Payer: Hawaii Western Management Group Commercial	$462.48
Rate for Payer: Health Management Network Commercial	$413.80
Rate for Payer: Humana Medicare	$243.41
Rate for Payer: Kaiser Permanente Commercial	$438.14
Rate for Payer: Kaiser Permanente Medicaid	$248.28
Rate for Payer: Kaiser Permanente Medicare	$243.41
Rate for Payer: MDX Hawaii PPO	$472.22
Rate for Payer: Ohana Health Plan Medicaid	$243.41
Rate for Payer: Ohana Health Plan Medicare	$243.41
Rate for Payer: UnitedHealthcare Medicaid	$292.09
Rate for Payer: UnitedHealthcare Medicare	$243.41
Rate for Payer: University Health Alliance Commercial	$354.84

Mechanical Traction Charge

Facility

$127.00

Service Code	HCPCS 97012 GP,CQ
Hospital Charge Code	8111701
Hospital Revenue Code	420
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Mechanical Traction Charge

Facility

$127.00

Service Code	HCPCS 97012 GP,CQ
Hospital Charge Code	8111701
Hospital Revenue Code	420
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Western Management Group Commercial	$120.65
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$13.69
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$92.57

meclizine 12.5 mg tablet [HHSC]

Facility

$3.94

Service Code	NDC 68084049001
Hospital Charge Code	2500514
Hospital Revenue Code	250
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$2.56
Rate for Payer: Health Management Network Commercial	$3.35
Rate for Payer: Kaiser Permanente Commercial	$3.55
Rate for Payer: MDX Hawaii PPO	$3.82

meclizine 12.5 mg tablet [HHSC]

Facility

$3.94

Service Code	NDC 60687077501
Hospital Charge Code	2500514
Hospital Revenue Code	250
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$3.82
Rate for Payer: AlohaCare Medicaid	$1.97
Rate for Payer: AlohaCare Medicare	$1.97
Rate for Payer: Cash Price	$2.56
Rate for Payer: Devoted Health Medicare	$2.17
Rate for Payer: Hawaii Medical Service Association Medicare	$1.97
Rate for Payer: Hawaii Western Management Group Commercial	$3.74
Rate for Payer: Health Management Network Commercial	$3.35
Rate for Payer: Humana Medicare	$1.97
Rate for Payer: Kaiser Permanente Commercial	$3.55
Rate for Payer: Kaiser Permanente Medicaid	$2.01
Rate for Payer: Kaiser Permanente Medicare	$1.97
Rate for Payer: MDX Hawaii PPO	$3.82
Rate for Payer: Ohana Health Plan Medicaid	$1.97
Rate for Payer: Ohana Health Plan Medicare	$1.97
Rate for Payer: UnitedHealthcare Medicaid	$2.36
Rate for Payer: UnitedHealthcare Medicare	$1.97
Rate for Payer: University Health Alliance Commercial	$2.87

meclizine 12.5 mg tablet [HHSC]

Facility

$3.94

Service Code	NDC 68084049001
Hospital Charge Code	2500514
Hospital Revenue Code	250
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$3.82
Rate for Payer: AlohaCare Medicaid	$1.97
Rate for Payer: AlohaCare Medicare	$1.97
Rate for Payer: Cash Price	$2.56
Rate for Payer: Devoted Health Medicare	$2.17
Rate for Payer: Hawaii Medical Service Association Medicare	$1.97
Rate for Payer: Hawaii Western Management Group Commercial	$3.74
Rate for Payer: Health Management Network Commercial	$3.35
Rate for Payer: Humana Medicare	$1.97
Rate for Payer: Kaiser Permanente Commercial	$3.55
Rate for Payer: Kaiser Permanente Medicaid	$2.01
Rate for Payer: Kaiser Permanente Medicare	$1.97
Rate for Payer: MDX Hawaii PPO	$3.82
Rate for Payer: Ohana Health Plan Medicaid	$1.97
Rate for Payer: Ohana Health Plan Medicare	$1.97
Rate for Payer: UnitedHealthcare Medicaid	$2.36
Rate for Payer: UnitedHealthcare Medicare	$1.97
Rate for Payer: University Health Alliance Commercial	$2.87

meclizine 12.5 mg tablet [HHSC]

Facility

$3.94

Service Code	NDC 60687077501
Hospital Charge Code	2500514
Hospital Revenue Code	250
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$3.82
Rate for Payer: Cash Price	$2.56
Rate for Payer: Health Management Network Commercial	$3.35
Rate for Payer: Kaiser Permanente Commercial	$3.55
Rate for Payer: MDX Hawaii PPO	$3.82

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 59746012106
Hospital Charge Code	2500515
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

meclizine 25 mg tablet [HHSC]

Facility

$4.69

Service Code	NDC 50268052315
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$4.55
Rate for Payer: AlohaCare Medicaid	$2.35
Rate for Payer: AlohaCare Medicare	$2.35
Rate for Payer: Cash Price	$3.05
Rate for Payer: Devoted Health Medicare	$2.58
Rate for Payer: Hawaii Medical Service Association Medicare	$2.35
Rate for Payer: Hawaii Western Management Group Commercial	$4.46
Rate for Payer: Health Management Network Commercial	$3.99
Rate for Payer: Humana Medicare	$2.35
Rate for Payer: Kaiser Permanente Commercial	$4.22
Rate for Payer: Kaiser Permanente Medicaid	$2.39
Rate for Payer: Kaiser Permanente Medicare	$2.35
Rate for Payer: MDX Hawaii PPO	$4.55
Rate for Payer: Ohana Health Plan Medicaid	$2.35
Rate for Payer: Ohana Health Plan Medicare	$2.35
Rate for Payer: UnitedHealthcare Medicaid	$2.81
Rate for Payer: UnitedHealthcare Medicare	$2.35
Rate for Payer: University Health Alliance Commercial	$3.42

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 68084049101
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$4.62
Rate for Payer: AlohaCare Medicaid	$2.38
Rate for Payer: AlohaCare Medicare	$2.38
Rate for Payer: Cash Price	$3.09
Rate for Payer: Devoted Health Medicare	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.38
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Humana Medicare	$2.38
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: Kaiser Permanente Medicaid	$2.43
Rate for Payer: Kaiser Permanente Medicare	$2.38
Rate for Payer: MDX Hawaii PPO	$4.62
Rate for Payer: Ohana Health Plan Medicaid	$2.38
Rate for Payer: Ohana Health Plan Medicare	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$2.86
Rate for Payer: UnitedHealthcare Medicare	$2.38
Rate for Payer: University Health Alliance Commercial	$3.47

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 68084049101
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.62
Rate for Payer: Cash Price	$3.09
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: MDX Hawaii PPO	$4.62

meclizine 25 mg tablet [HHSC]

Facility

$4.69

Service Code	NDC 50268052315
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$4.55
Rate for Payer: Cash Price	$3.05
Rate for Payer: Health Management Network Commercial	$3.99
Rate for Payer: Kaiser Permanente Commercial	$4.22
Rate for Payer: MDX Hawaii PPO	$4.55

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 16571066101
Hospital Charge Code	2500515
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

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 59746012106
Hospital Charge Code	2500515
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

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 60687073001
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$4.62
Rate for Payer: AlohaCare Medicaid	$2.38
Rate for Payer: AlohaCare Medicare	$2.38
Rate for Payer: Cash Price	$3.09
Rate for Payer: Devoted Health Medicare	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.38
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Humana Medicare	$2.38
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: Kaiser Permanente Medicaid	$2.43
Rate for Payer: Kaiser Permanente Medicare	$2.38
Rate for Payer: MDX Hawaii PPO	$4.62
Rate for Payer: Ohana Health Plan Medicaid	$2.38
Rate for Payer: Ohana Health Plan Medicare	$2.38
Rate for Payer: UnitedHealthcare Medicaid	$2.86
Rate for Payer: UnitedHealthcare Medicare	$2.38
Rate for Payer: University Health Alliance Commercial	$3.47

meclizine 25 mg tablet [HHSC]

Facility

$4.76

Service Code	NDC 60687073001
Hospital Charge Code	2500515
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.62
Rate for Payer: Cash Price	$3.09
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: MDX Hawaii PPO	$4.62

meclizine 25 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 16571066101
Hospital Charge Code	2500515
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

.Meconium Drug Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395735
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$147.65

.Meconium Drug Screen FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395735
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

MEDICAL BACK PROBLEMS WITH MCC

Facility

$15,756.53

Service Code	MSDRG 551
Min. Negotiated Rate	$15,756.53
Max. Negotiated Rate	$15,756.53
Rate for Payer: Hawaii Medical Service Association Commercial	$15,756.53

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$15,756.53

Service Code	MSDRG 552
Min. Negotiated Rate	$15,756.53
Max. Negotiated Rate	$15,756.53
Rate for Payer: Hawaii Medical Service Association Commercial	$15,756.53

Know your out-of-pocket cost for care.

All Charges