Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$23.83

Service Code	NDC 60687063365
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$11.91
Max. Negotiated Rate	$23.12
Rate for Payer: AlohaCare Medicaid	$11.91
Rate for Payer: AlohaCare Medicare	$11.91
Rate for Payer: Cash Price	$15.49
Rate for Payer: Devoted Health Medicare	$13.11
Rate for Payer: Hawaii Medical Service Association Medicare	$11.91
Rate for Payer: Hawaii Western Management Group Commercial	$22.64
Rate for Payer: Health Management Network Commercial	$20.26
Rate for Payer: Humana Medicare	$11.91
Rate for Payer: Kaiser Permanente Commercial	$21.45
Rate for Payer: Kaiser Permanente Medicaid	$12.15
Rate for Payer: Kaiser Permanente Medicare	$11.91
Rate for Payer: MDX Hawaii PPO	$23.12
Rate for Payer: Ohana Health Plan Medicaid	$11.91
Rate for Payer: Ohana Health Plan Medicare	$11.91
Rate for Payer: UnitedHealthcare Medicaid	$14.30
Rate for Payer: UnitedHealthcare Medicare	$11.91
Rate for Payer: University Health Alliance Commercial	$17.37

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$20.94

Service Code	NDC 68001042300
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$20.31
Rate for Payer: AlohaCare Medicaid	$10.47
Rate for Payer: AlohaCare Medicare	$10.47
Rate for Payer: Cash Price	$13.61
Rate for Payer: Devoted Health Medicare	$11.52
Rate for Payer: Hawaii Medical Service Association Medicare	$10.47
Rate for Payer: Hawaii Western Management Group Commercial	$19.89
Rate for Payer: Health Management Network Commercial	$17.80
Rate for Payer: Humana Medicare	$10.47
Rate for Payer: Kaiser Permanente Commercial	$18.85
Rate for Payer: Kaiser Permanente Medicaid	$10.68
Rate for Payer: Kaiser Permanente Medicare	$10.47
Rate for Payer: MDX Hawaii PPO	$20.31
Rate for Payer: Ohana Health Plan Medicaid	$10.47
Rate for Payer: Ohana Health Plan Medicare	$10.47
Rate for Payer: UnitedHealthcare Medicaid	$12.56
Rate for Payer: UnitedHealthcare Medicare	$10.47
Rate for Payer: University Health Alliance Commercial	$15.26

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$20.94

Service Code	NDC 68001000100
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$17.80
Max. Negotiated Rate	$20.31
Rate for Payer: Cash Price	$13.61
Rate for Payer: Health Management Network Commercial	$17.80
Rate for Payer: Kaiser Permanente Commercial	$18.85
Rate for Payer: MDX Hawaii PPO	$20.31

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$9.39

Service Code	NDC 13811071910
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$9.11
Rate for Payer: Cash Price	$6.10
Rate for Payer: Health Management Network Commercial	$7.98
Rate for Payer: Kaiser Permanente Commercial	$8.45
Rate for Payer: MDX Hawaii PPO	$9.11

nitroglycerin 0.2 mg/hr patch [HHSC]

Facility

$10.58

Service Code	NDC 68382030930
Hospital Charge Code	2500586
Hospital Revenue Code	250
Min. Negotiated Rate	$5.29
Max. Negotiated Rate	$10.26
Rate for Payer: AlohaCare Medicaid	$5.29
Rate for Payer: AlohaCare Medicare	$5.29
Rate for Payer: Cash Price	$6.88
Rate for Payer: Devoted Health Medicare	$5.82
Rate for Payer: Hawaii Medical Service Association Medicare	$5.29
Rate for Payer: Hawaii Western Management Group Commercial	$10.05
Rate for Payer: Health Management Network Commercial	$8.99
Rate for Payer: Humana Medicare	$5.29
Rate for Payer: Kaiser Permanente Commercial	$9.52
Rate for Payer: Kaiser Permanente Medicaid	$5.40
Rate for Payer: Kaiser Permanente Medicare	$5.29
Rate for Payer: MDX Hawaii PPO	$10.26
Rate for Payer: Ohana Health Plan Medicaid	$5.29
Rate for Payer: Ohana Health Plan Medicare	$5.29
Rate for Payer: UnitedHealthcare Medicaid	$6.35
Rate for Payer: UnitedHealthcare Medicare	$5.29
Rate for Payer: University Health Alliance Commercial	$7.71

nitroglycerin 0.2 mg/hr patch [HHSC]

Facility

$10.58

Service Code	NDC 68382030930
Hospital Charge Code	2500586
Hospital Revenue Code	250
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$10.26
Rate for Payer: Cash Price	$6.88
Rate for Payer: Health Management Network Commercial	$8.99
Rate for Payer: Kaiser Permanente Commercial	$9.52
Rate for Payer: MDX Hawaii PPO	$10.26

nitroglycerin 0.2 mg/hr patch [HHSC]

Facility

$10.58

Service Code	NDC 00378910493
Hospital Charge Code	2500586
Hospital Revenue Code	250
Min. Negotiated Rate	$5.29
Max. Negotiated Rate	$10.26
Rate for Payer: AlohaCare Medicaid	$5.29
Rate for Payer: AlohaCare Medicare	$5.29
Rate for Payer: Cash Price	$6.88
Rate for Payer: Devoted Health Medicare	$5.82
Rate for Payer: Hawaii Medical Service Association Medicare	$5.29
Rate for Payer: Hawaii Western Management Group Commercial	$10.05
Rate for Payer: Health Management Network Commercial	$8.99
Rate for Payer: Humana Medicare	$5.29
Rate for Payer: Kaiser Permanente Commercial	$9.52
Rate for Payer: Kaiser Permanente Medicaid	$5.40
Rate for Payer: Kaiser Permanente Medicare	$5.29
Rate for Payer: MDX Hawaii PPO	$10.26
Rate for Payer: Ohana Health Plan Medicaid	$5.29
Rate for Payer: Ohana Health Plan Medicare	$5.29
Rate for Payer: UnitedHealthcare Medicaid	$6.35
Rate for Payer: UnitedHealthcare Medicare	$5.29
Rate for Payer: University Health Alliance Commercial	$7.71

nitroglycerin 0.2 mg/hr patch [HHSC]

Facility

$10.58

Service Code	NDC 00378910493
Hospital Charge Code	2500586
Hospital Revenue Code	250
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$10.26
Rate for Payer: Cash Price	$6.88
Rate for Payer: Health Management Network Commercial	$8.99
Rate for Payer: Kaiser Permanente Commercial	$9.52
Rate for Payer: MDX Hawaii PPO	$10.26

nitroglycerin 0.4 mg/hr patch [HHSC]

Facility

$12.08

Service Code	NDC 00378911293
Hospital Charge Code	2500588
Hospital Revenue Code	250
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$11.72
Rate for Payer: AlohaCare Medicaid	$6.04
Rate for Payer: AlohaCare Medicare	$6.04
Rate for Payer: Cash Price	$7.85
Rate for Payer: Devoted Health Medicare	$6.64
Rate for Payer: Hawaii Medical Service Association Medicare	$6.04
Rate for Payer: Hawaii Western Management Group Commercial	$11.48
Rate for Payer: Health Management Network Commercial	$10.27
Rate for Payer: Humana Medicare	$6.04
Rate for Payer: Kaiser Permanente Commercial	$10.87
Rate for Payer: Kaiser Permanente Medicaid	$6.16
Rate for Payer: Kaiser Permanente Medicare	$6.04
Rate for Payer: MDX Hawaii PPO	$11.72
Rate for Payer: Ohana Health Plan Medicaid	$6.04
Rate for Payer: Ohana Health Plan Medicare	$6.04
Rate for Payer: UnitedHealthcare Medicaid	$7.25
Rate for Payer: UnitedHealthcare Medicare	$6.04
Rate for Payer: University Health Alliance Commercial	$8.81

nitroglycerin 0.4 mg/hr patch [HHSC]

Facility

$16.17

Service Code	NDC 47781029803
Hospital Charge Code	2500588
Hospital Revenue Code	250
Min. Negotiated Rate	$8.09
Max. Negotiated Rate	$15.68
Rate for Payer: AlohaCare Medicaid	$8.09
Rate for Payer: AlohaCare Medicare	$8.09
Rate for Payer: Cash Price	$10.51
Rate for Payer: Devoted Health Medicare	$8.89
Rate for Payer: Hawaii Medical Service Association Medicare	$8.09
Rate for Payer: Hawaii Western Management Group Commercial	$15.36
Rate for Payer: Health Management Network Commercial	$13.74
Rate for Payer: Humana Medicare	$8.09
Rate for Payer: Kaiser Permanente Commercial	$14.55
Rate for Payer: Kaiser Permanente Medicaid	$8.25
Rate for Payer: Kaiser Permanente Medicare	$8.09
Rate for Payer: MDX Hawaii PPO	$15.68
Rate for Payer: Ohana Health Plan Medicaid	$8.09
Rate for Payer: Ohana Health Plan Medicare	$8.09
Rate for Payer: UnitedHealthcare Medicaid	$9.70
Rate for Payer: UnitedHealthcare Medicare	$8.09
Rate for Payer: University Health Alliance Commercial	$11.79

nitroglycerin 0.4 mg/hr patch [HHSC]

Facility

$12.08

Service Code	NDC 00378911293
Hospital Charge Code	2500588
Hospital Revenue Code	250
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$11.72
Rate for Payer: Cash Price	$7.85
Rate for Payer: Health Management Network Commercial	$10.27
Rate for Payer: Kaiser Permanente Commercial	$10.87
Rate for Payer: MDX Hawaii PPO	$11.72

nitroglycerin 0.4 mg/hr patch [HHSC]

Facility

$16.17

Service Code	NDC 47781029803
Hospital Charge Code	2500588
Hospital Revenue Code	250
Min. Negotiated Rate	$13.74
Max. Negotiated Rate	$15.68
Rate for Payer: Cash Price	$10.51
Rate for Payer: Health Management Network Commercial	$13.74
Rate for Payer: Kaiser Permanente Commercial	$14.55
Rate for Payer: MDX Hawaii PPO	$15.68

nitroglycerin 2% ointment 1gm [HHSC]

Facility

$13.94

Service Code	NDC 00281032608
Hospital Charge Code	2500589
Hospital Revenue Code	250
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$13.52
Rate for Payer: AlohaCare Medicaid	$6.97
Rate for Payer: AlohaCare Medicare	$6.97
Rate for Payer: Cash Price	$9.06
Rate for Payer: Devoted Health Medicare	$7.67
Rate for Payer: Hawaii Medical Service Association Medicare	$6.97
Rate for Payer: Hawaii Western Management Group Commercial	$13.24
Rate for Payer: Health Management Network Commercial	$11.85
Rate for Payer: Humana Medicare	$6.97
Rate for Payer: Kaiser Permanente Commercial	$12.55
Rate for Payer: Kaiser Permanente Medicaid	$7.11
Rate for Payer: Kaiser Permanente Medicare	$6.97
Rate for Payer: MDX Hawaii PPO	$13.52
Rate for Payer: Ohana Health Plan Medicaid	$6.97
Rate for Payer: Ohana Health Plan Medicare	$6.97
Rate for Payer: UnitedHealthcare Medicaid	$8.36
Rate for Payer: UnitedHealthcare Medicare	$6.97
Rate for Payer: University Health Alliance Commercial	$10.16

nitroglycerin 2% ointment 1gm [HHSC]

Facility

$13.94

Service Code	NDC 00281032608
Hospital Charge Code	2500589
Hospital Revenue Code	250
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$13.52
Rate for Payer: Cash Price	$9.06
Rate for Payer: Health Management Network Commercial	$11.85
Rate for Payer: Kaiser Permanente Commercial	$12.55
Rate for Payer: MDX Hawaii PPO	$13.52

nitroglycerin-d5w 0.2 mg/ml 250ml [HHSC]

Facility

$115.08

Service Code	NDC 00338104902
Hospital Charge Code	2500591
Hospital Revenue Code	250
Min. Negotiated Rate	$97.82
Max. Negotiated Rate	$111.63
Rate for Payer: Cash Price	$74.80
Rate for Payer: Health Management Network Commercial	$97.82
Rate for Payer: Kaiser Permanente Commercial	$103.57
Rate for Payer: MDX Hawaii PPO	$111.63

nitroglycerin-d5w 0.2 mg/ml 250ml [HHSC]

Facility

$115.08

Service Code	NDC 00338104902
Hospital Charge Code	2500591
Hospital Revenue Code	250
Min. Negotiated Rate	$57.54
Max. Negotiated Rate	$111.63
Rate for Payer: AlohaCare Medicaid	$57.54
Rate for Payer: AlohaCare Medicare	$57.54
Rate for Payer: Cash Price	$74.80
Rate for Payer: Devoted Health Medicare	$63.29
Rate for Payer: Hawaii Medical Service Association Medicare	$57.54
Rate for Payer: Hawaii Western Management Group Commercial	$109.33
Rate for Payer: Health Management Network Commercial	$97.82
Rate for Payer: Humana Medicare	$57.54
Rate for Payer: Kaiser Permanente Commercial	$103.57
Rate for Payer: Kaiser Permanente Medicaid	$58.69
Rate for Payer: Kaiser Permanente Medicare	$57.54
Rate for Payer: MDX Hawaii PPO	$111.63
Rate for Payer: Ohana Health Plan Medicaid	$57.54
Rate for Payer: Ohana Health Plan Medicare	$57.54
Rate for Payer: UnitedHealthcare Medicaid	$69.05
Rate for Payer: UnitedHealthcare Medicare	$57.54
Rate for Payer: University Health Alliance Commercial	$83.88

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$148.65

Service Code	NDC 00071041813
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$74.33
Max. Negotiated Rate	$144.19
Rate for Payer: AlohaCare Medicaid	$74.33
Rate for Payer: AlohaCare Medicare	$74.33
Rate for Payer: Cash Price	$96.62
Rate for Payer: Devoted Health Medicare	$81.76
Rate for Payer: Hawaii Medical Service Association Medicare	$74.33
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$126.35
Rate for Payer: Humana Medicare	$74.33
Rate for Payer: Kaiser Permanente Commercial	$133.78
Rate for Payer: Kaiser Permanente Medicaid	$75.81
Rate for Payer: Kaiser Permanente Medicare	$74.33
Rate for Payer: MDX Hawaii PPO	$144.19
Rate for Payer: Ohana Health Plan Medicaid	$74.33
Rate for Payer: Ohana Health Plan Medicare	$74.33
Rate for Payer: UnitedHealthcare Medicaid	$89.19
Rate for Payer: UnitedHealthcare Medicare	$74.33
Rate for Payer: University Health Alliance Commercial	$108.35

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$148.65

Service Code	NDC 00071041813
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$126.35
Max. Negotiated Rate	$144.19
Rate for Payer: Cash Price	$96.62
Rate for Payer: Health Management Network Commercial	$126.35
Rate for Payer: Kaiser Permanente Commercial	$133.78
Rate for Payer: MDX Hawaii PPO	$144.19

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 59762330403
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$121.70
Rate for Payer: AlohaCare Medicaid	$62.73
Rate for Payer: AlohaCare Medicare	$62.73
Rate for Payer: Cash Price	$81.55
Rate for Payer: Devoted Health Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Medicare	$62.73
Rate for Payer: Hawaii Western Management Group Commercial	$119.19
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Humana Medicare	$62.73
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: Kaiser Permanente Medicaid	$63.98
Rate for Payer: Kaiser Permanente Medicare	$62.73
Rate for Payer: MDX Hawaii PPO	$121.70
Rate for Payer: Ohana Health Plan Medicaid	$62.73
Rate for Payer: Ohana Health Plan Medicare	$62.73
Rate for Payer: UnitedHealthcare Medicaid	$75.28
Rate for Payer: UnitedHealthcare Medicare	$62.73
Rate for Payer: University Health Alliance Commercial	$91.45

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 59762330403
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$106.64
Max. Negotiated Rate	$121.70
Rate for Payer: Cash Price	$81.55
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: MDX Hawaii PPO	$121.70

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 70756001402
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$106.64
Max. Negotiated Rate	$121.70
Rate for Payer: Cash Price	$81.55
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: MDX Hawaii PPO	$121.70

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 70756001402
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$121.70
Rate for Payer: AlohaCare Medicaid	$62.73
Rate for Payer: AlohaCare Medicare	$62.73
Rate for Payer: Cash Price	$81.55
Rate for Payer: Devoted Health Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Medicare	$62.73
Rate for Payer: Hawaii Western Management Group Commercial	$119.19
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Humana Medicare	$62.73
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: Kaiser Permanente Medicaid	$63.98
Rate for Payer: Kaiser Permanente Medicare	$62.73
Rate for Payer: MDX Hawaii PPO	$121.70
Rate for Payer: Ohana Health Plan Medicaid	$62.73
Rate for Payer: Ohana Health Plan Medicare	$62.73
Rate for Payer: UnitedHealthcare Medicaid	$75.28
Rate for Payer: UnitedHealthcare Medicare	$62.73
Rate for Payer: University Health Alliance Commercial	$91.45

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 68462063945
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$121.70
Rate for Payer: AlohaCare Medicaid	$62.73
Rate for Payer: AlohaCare Medicare	$62.73
Rate for Payer: Cash Price	$81.55
Rate for Payer: Devoted Health Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Medicare	$62.73
Rate for Payer: Hawaii Western Management Group Commercial	$119.19
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Humana Medicare	$62.73
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: Kaiser Permanente Medicaid	$63.98
Rate for Payer: Kaiser Permanente Medicare	$62.73
Rate for Payer: MDX Hawaii PPO	$121.70
Rate for Payer: Ohana Health Plan Medicaid	$62.73
Rate for Payer: Ohana Health Plan Medicare	$62.73
Rate for Payer: UnitedHealthcare Medicaid	$75.28
Rate for Payer: UnitedHealthcare Medicare	$62.73
Rate for Payer: University Health Alliance Commercial	$91.45

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 68462063945
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$106.64
Max. Negotiated Rate	$121.70
Rate for Payer: Cash Price	$81.55
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: MDX Hawaii PPO	$121.70

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$188.19

Service Code	NDC 72485010501
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$159.96
Max. Negotiated Rate	$182.54
Rate for Payer: Cash Price	$122.32
Rate for Payer: Health Management Network Commercial	$159.96
Rate for Payer: Kaiser Permanente Commercial	$169.37
Rate for Payer: MDX Hawaii PPO	$182.54

Know your out-of-pocket cost for care.

All Charges