Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

midodrine 2.5 mg tablet [HHSC]

Facility

$9.40

Service Code	NDC 00245021111
Hospital Charge Code	2500552
Hospital Revenue Code	250
Min. Negotiated Rate	$7.99
Max. Negotiated Rate	$9.12
Rate for Payer: Cash Price	$6.11
Rate for Payer: Health Management Network Commercial	$7.99
Rate for Payer: Kaiser Permanente Commercial	$8.46
Rate for Payer: MDX Hawaii PPO	$9.12

midodrine 2.5 mg tablet [HHSC]

Facility

$8.45

Service Code	NDC 82293000310
Hospital Charge Code	2500552
Hospital Revenue Code	250
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$8.20
Rate for Payer: AlohaCare Medicaid	$4.22
Rate for Payer: AlohaCare Medicare	$4.22
Rate for Payer: Cash Price	$5.49
Rate for Payer: Devoted Health Medicare	$4.65
Rate for Payer: Hawaii Medical Service Association Medicare	$4.22
Rate for Payer: Hawaii Western Management Group Commercial	$8.03
Rate for Payer: Health Management Network Commercial	$7.18
Rate for Payer: Humana Medicare	$4.22
Rate for Payer: Kaiser Permanente Commercial	$7.61
Rate for Payer: Kaiser Permanente Medicaid	$4.31
Rate for Payer: Kaiser Permanente Medicare	$4.22
Rate for Payer: MDX Hawaii PPO	$8.20
Rate for Payer: Ohana Health Plan Medicaid	$4.22
Rate for Payer: Ohana Health Plan Medicare	$4.22
Rate for Payer: UnitedHealthcare Medicaid	$5.07
Rate for Payer: UnitedHealthcare Medicare	$4.22
Rate for Payer: University Health Alliance Commercial	$6.16

midodrine 2.5 mg tablet [HHSC]

Facility

$9.40

Service Code	NDC 00245021111
Hospital Charge Code	2500552
Hospital Revenue Code	250
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$9.12
Rate for Payer: AlohaCare Medicaid	$4.70
Rate for Payer: AlohaCare Medicare	$4.70
Rate for Payer: Cash Price	$6.11
Rate for Payer: Devoted Health Medicare	$5.17
Rate for Payer: Hawaii Medical Service Association Medicare	$4.70
Rate for Payer: Hawaii Western Management Group Commercial	$8.93
Rate for Payer: Health Management Network Commercial	$7.99
Rate for Payer: Humana Medicare	$4.70
Rate for Payer: Kaiser Permanente Commercial	$8.46
Rate for Payer: Kaiser Permanente Medicaid	$4.79
Rate for Payer: Kaiser Permanente Medicare	$4.70
Rate for Payer: MDX Hawaii PPO	$9.12
Rate for Payer: Ohana Health Plan Medicaid	$4.70
Rate for Payer: Ohana Health Plan Medicare	$4.70
Rate for Payer: UnitedHealthcare Medicaid	$5.64
Rate for Payer: UnitedHealthcare Medicare	$4.70
Rate for Payer: University Health Alliance Commercial	$6.85

midodrine 2.5 mg tablet [HHSC]

Facility

$14.76

Service Code	NDC 50268056415
Hospital Charge Code	2500552
Hospital Revenue Code	250
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$14.32
Rate for Payer: AlohaCare Medicaid	$7.38
Rate for Payer: AlohaCare Medicare	$7.38
Rate for Payer: Cash Price	$9.59
Rate for Payer: Devoted Health Medicare	$8.12
Rate for Payer: Hawaii Medical Service Association Medicare	$7.38
Rate for Payer: Hawaii Western Management Group Commercial	$14.02
Rate for Payer: Health Management Network Commercial	$12.55
Rate for Payer: Humana Medicare	$7.38
Rate for Payer: Kaiser Permanente Commercial	$13.28
Rate for Payer: Kaiser Permanente Medicaid	$7.53
Rate for Payer: Kaiser Permanente Medicare	$7.38
Rate for Payer: MDX Hawaii PPO	$14.32
Rate for Payer: Ohana Health Plan Medicaid	$7.38
Rate for Payer: Ohana Health Plan Medicare	$7.38
Rate for Payer: UnitedHealthcare Medicaid	$8.86
Rate for Payer: UnitedHealthcare Medicare	$7.38
Rate for Payer: University Health Alliance Commercial	$10.76

midodrine 2.5 mg tablet [HHSC]

Facility

$3.91

Service Code	NDC 00904681706
Hospital Charge Code	2500552
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$3.79
Rate for Payer: AlohaCare Medicaid	$1.96
Rate for Payer: AlohaCare Medicare	$1.96
Rate for Payer: Cash Price	$2.54
Rate for Payer: Devoted Health Medicare	$2.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1.96
Rate for Payer: Hawaii Western Management Group Commercial	$3.71
Rate for Payer: Health Management Network Commercial	$3.32
Rate for Payer: Humana Medicare	$1.96
Rate for Payer: Kaiser Permanente Commercial	$3.52
Rate for Payer: Kaiser Permanente Medicaid	$1.99
Rate for Payer: Kaiser Permanente Medicare	$1.96
Rate for Payer: MDX Hawaii PPO	$3.79
Rate for Payer: Ohana Health Plan Medicaid	$1.96
Rate for Payer: Ohana Health Plan Medicare	$1.96
Rate for Payer: UnitedHealthcare Medicaid	$2.35
Rate for Payer: UnitedHealthcare Medicare	$1.96
Rate for Payer: University Health Alliance Commercial	$2.85

midodrine 2.5 mg tablet [HHSC]

Facility

$7.96

Service Code	NDC 60687038701
Hospital Charge Code	2500552
Hospital Revenue Code	250
Min. Negotiated Rate	$3.98
Max. Negotiated Rate	$7.72
Rate for Payer: AlohaCare Medicaid	$3.98
Rate for Payer: AlohaCare Medicare	$3.98
Rate for Payer: Cash Price	$5.17
Rate for Payer: Devoted Health Medicare	$4.38
Rate for Payer: Hawaii Medical Service Association Medicare	$3.98
Rate for Payer: Hawaii Western Management Group Commercial	$7.56
Rate for Payer: Health Management Network Commercial	$6.77
Rate for Payer: Humana Medicare	$3.98
Rate for Payer: Kaiser Permanente Commercial	$7.16
Rate for Payer: Kaiser Permanente Medicaid	$4.06
Rate for Payer: Kaiser Permanente Medicare	$3.98
Rate for Payer: MDX Hawaii PPO	$7.72
Rate for Payer: Ohana Health Plan Medicaid	$3.98
Rate for Payer: Ohana Health Plan Medicare	$3.98
Rate for Payer: UnitedHealthcare Medicaid	$4.78
Rate for Payer: UnitedHealthcare Medicare	$3.98
Rate for Payer: University Health Alliance Commercial	$5.80

Milk, IgE w/ Reflex Alpha Lactalbumin, Beta Lactalbumin, Casein FSI

Facility

$137.00

Hospital Charge Code	8117995
Hospital Revenue Code	302
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$132.89
Rate for Payer: AlohaCare Medicaid	$68.50
Rate for Payer: AlohaCare Medicare	$68.50
Rate for Payer: Cash Price	$89.05
Rate for Payer: Devoted Health Medicare	$75.35
Rate for Payer: Hawaii Medical Service Association Medicare	$68.50
Rate for Payer: Hawaii Western Management Group Commercial	$130.15
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Humana Medicare	$68.50
Rate for Payer: Kaiser Permanente Commercial	$123.30
Rate for Payer: Kaiser Permanente Medicaid	$69.87
Rate for Payer: Kaiser Permanente Medicare	$68.50
Rate for Payer: MDX Hawaii PPO	$132.89
Rate for Payer: Ohana Health Plan Medicaid	$68.50
Rate for Payer: Ohana Health Plan Medicare	$68.50
Rate for Payer: UnitedHealthcare Medicare	$68.50
Rate for Payer: University Health Alliance Commercial	$99.86

Milk, IgE w/ Reflex Alpha Lactalbumin, Beta Lactalbumin, Casein FSI

Facility

$137.00

Hospital Charge Code	8117995
Hospital Revenue Code	302
Min. Negotiated Rate	$116.45
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$89.05
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Kaiser Permanente Commercial	$123.30
Rate for Payer: MDX Hawaii PPO	$132.89

mineral oil 10ml vial [HHSC]

Facility

$87.97

Service Code	NDC 63323025410
Hospital Charge Code	2500553
Hospital Revenue Code	250
Min. Negotiated Rate	$43.98
Max. Negotiated Rate	$85.33
Rate for Payer: AlohaCare Medicaid	$43.98
Rate for Payer: AlohaCare Medicare	$43.98
Rate for Payer: Cash Price	$57.18
Rate for Payer: Devoted Health Medicare	$48.38
Rate for Payer: Hawaii Medical Service Association Medicare	$43.98
Rate for Payer: Hawaii Western Management Group Commercial	$83.57
Rate for Payer: Health Management Network Commercial	$74.77
Rate for Payer: Humana Medicare	$43.98
Rate for Payer: Kaiser Permanente Commercial	$79.17
Rate for Payer: Kaiser Permanente Medicaid	$44.86
Rate for Payer: Kaiser Permanente Medicare	$43.98
Rate for Payer: MDX Hawaii PPO	$85.33
Rate for Payer: Ohana Health Plan Medicaid	$43.98
Rate for Payer: Ohana Health Plan Medicare	$43.98
Rate for Payer: UnitedHealthcare Medicaid	$52.78
Rate for Payer: UnitedHealthcare Medicare	$43.98
Rate for Payer: University Health Alliance Commercial	$64.12

mineral oil 10ml vial [HHSC]

Facility

$87.97

Service Code	NDC 63323025410
Hospital Charge Code	2500553
Hospital Revenue Code	250
Min. Negotiated Rate	$74.77
Max. Negotiated Rate	$85.33
Rate for Payer: Cash Price	$57.18
Rate for Payer: Health Management Network Commercial	$74.77
Rate for Payer: Kaiser Permanente Commercial	$79.17
Rate for Payer: MDX Hawaii PPO	$85.33

mineral oil enema 133 mL [HHSC]

Facility

$11.56

Service Code	NDC 00132030140
Hospital Charge Code	2500554
Hospital Revenue Code	250
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$11.21
Rate for Payer: AlohaCare Medicaid	$5.78
Rate for Payer: AlohaCare Medicare	$5.78
Rate for Payer: Cash Price	$7.51
Rate for Payer: Devoted Health Medicare	$6.36
Rate for Payer: Hawaii Medical Service Association Medicare	$5.78
Rate for Payer: Hawaii Western Management Group Commercial	$10.98
Rate for Payer: Health Management Network Commercial	$9.83
Rate for Payer: Humana Medicare	$5.78
Rate for Payer: Kaiser Permanente Commercial	$10.40
Rate for Payer: Kaiser Permanente Medicaid	$5.90
Rate for Payer: Kaiser Permanente Medicare	$5.78
Rate for Payer: MDX Hawaii PPO	$11.21
Rate for Payer: Ohana Health Plan Medicaid	$5.78
Rate for Payer: Ohana Health Plan Medicare	$5.78
Rate for Payer: UnitedHealthcare Medicaid	$6.94
Rate for Payer: UnitedHealthcare Medicare	$5.78
Rate for Payer: University Health Alliance Commercial	$8.43

mineral oil enema 133 mL [HHSC]

Facility

$11.56

Service Code	NDC 00132030140
Hospital Charge Code	2500554
Hospital Revenue Code	250
Min. Negotiated Rate	$9.83
Max. Negotiated Rate	$11.21
Rate for Payer: Cash Price	$7.51
Rate for Payer: Health Management Network Commercial	$9.83
Rate for Payer: Kaiser Permanente Commercial	$10.40
Rate for Payer: MDX Hawaii PPO	$11.21

MINOR BLADDER PROCEDURES WITH CC

Facility

$26,209.89

Service Code	MSDRG 663
Min. Negotiated Rate	$26,209.89
Max. Negotiated Rate	$26,209.89
Rate for Payer: Hawaii Medical Service Association Commercial	$26,209.89

MINOR BLADDER PROCEDURES WITH MCC

Facility

$35,311.96

Service Code	MSDRG 662
Min. Negotiated Rate	$35,311.96
Max. Negotiated Rate	$35,311.96
Rate for Payer: Hawaii Medical Service Association Commercial	$35,311.96

MINOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$20,600.77

Service Code	MSDRG 664
Min. Negotiated Rate	$20,600.77
Max. Negotiated Rate	$20,600.77
Rate for Payer: Hawaii Medical Service Association Commercial	$20,600.77

MINOR SKIN DISORDERS WITH MCC

Facility

$14,966.15

Service Code	MSDRG 606
Min. Negotiated Rate	$14,966.15
Max. Negotiated Rate	$14,966.15
Rate for Payer: Hawaii Medical Service Association Commercial	$14,966.15

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$13,487.38

Service Code	MSDRG 607
Min. Negotiated Rate	$13,487.38
Max. Negotiated Rate	$13,487.38
Rate for Payer: Hawaii Medical Service Association Commercial	$13,487.38

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$34,904.02

Service Code	MSDRG 345
Min. Negotiated Rate	$34,904.02
Max. Negotiated Rate	$34,904.02
Rate for Payer: Hawaii Medical Service Association Commercial	$34,904.02

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$39,034.38

Service Code	MSDRG 344
Min. Negotiated Rate	$39,034.38
Max. Negotiated Rate	$39,034.38
Rate for Payer: Hawaii Medical Service Association Commercial	$39,034.38

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$28,708.50

Service Code	MSDRG 346
Min. Negotiated Rate	$28,708.50
Max. Negotiated Rate	$28,708.50
Rate for Payer: Hawaii Medical Service Association Commercial	$28,708.50

mirtazapine 15 mg tablet [HHSC]

Facility

$15.06

Service Code	NDC 68084011901
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$7.53
Max. Negotiated Rate	$14.61
Rate for Payer: AlohaCare Medicaid	$7.53
Rate for Payer: AlohaCare Medicare	$7.53
Rate for Payer: Cash Price	$9.79
Rate for Payer: Devoted Health Medicare	$8.28
Rate for Payer: Hawaii Medical Service Association Medicare	$7.53
Rate for Payer: Hawaii Western Management Group Commercial	$14.31
Rate for Payer: Health Management Network Commercial	$12.80
Rate for Payer: Humana Medicare	$7.53
Rate for Payer: Kaiser Permanente Commercial	$13.55
Rate for Payer: Kaiser Permanente Medicaid	$7.68
Rate for Payer: Kaiser Permanente Medicare	$7.53
Rate for Payer: MDX Hawaii PPO	$14.61
Rate for Payer: Ohana Health Plan Medicaid	$7.53
Rate for Payer: Ohana Health Plan Medicare	$7.53
Rate for Payer: UnitedHealthcare Medicaid	$9.04
Rate for Payer: UnitedHealthcare Medicare	$7.53
Rate for Payer: University Health Alliance Commercial	$10.98

mirtazapine 15 mg tablet [HHSC]

Facility

$15.90

Service Code	NDC 00904651961
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$15.42
Rate for Payer: AlohaCare Medicaid	$7.95
Rate for Payer: AlohaCare Medicare	$7.95
Rate for Payer: Cash Price	$10.34
Rate for Payer: Devoted Health Medicare	$8.74
Rate for Payer: Hawaii Medical Service Association Medicare	$7.95
Rate for Payer: Hawaii Western Management Group Commercial	$15.11
Rate for Payer: Health Management Network Commercial	$13.52
Rate for Payer: Humana Medicare	$7.95
Rate for Payer: Kaiser Permanente Commercial	$14.31
Rate for Payer: Kaiser Permanente Medicaid	$8.11
Rate for Payer: Kaiser Permanente Medicare	$7.95
Rate for Payer: MDX Hawaii PPO	$15.42
Rate for Payer: Ohana Health Plan Medicaid	$7.95
Rate for Payer: Ohana Health Plan Medicare	$7.95
Rate for Payer: UnitedHealthcare Medicaid	$9.54
Rate for Payer: UnitedHealthcare Medicare	$7.95
Rate for Payer: University Health Alliance Commercial	$11.59

mirtazapine 15 mg tablet [HHSC]

Facility

$15.90

Service Code	NDC 00904651961
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$15.42
Rate for Payer: Cash Price	$10.34
Rate for Payer: Health Management Network Commercial	$13.52
Rate for Payer: Kaiser Permanente Commercial	$14.31
Rate for Payer: MDX Hawaii PPO	$15.42

mirtazapine 15 mg tablet [HHSC]

Facility

$15.06

Service Code	NDC 68084011901
Hospital Charge Code	2500555
Hospital Revenue Code	250
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$14.61
Rate for Payer: Cash Price	$9.79
Rate for Payer: Health Management Network Commercial	$12.80
Rate for Payer: Kaiser Permanente Commercial	$13.55
Rate for Payer: MDX Hawaii PPO	$14.61

Miscellaneous Culture FSI

Facility

$127.00

Service Code	HCPCS 87070
Hospital Charge Code	8117996
Hospital Revenue Code	306
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

Know your out-of-pocket cost for care.

All Charges