Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

nystatin 100000 units/ml 60ml [HHSC]

Facility

$78.34

Service Code	NDC 69315050460
Hospital Charge Code	2500594
Hospital Revenue Code	250
Min. Negotiated Rate	$66.59
Max. Negotiated Rate	$75.99
Rate for Payer: Cash Price	$50.92
Rate for Payer: Health Management Network Commercial	$66.59
Rate for Payer: Kaiser Permanente Commercial	$70.51
Rate for Payer: MDX Hawaii PPO	$75.99

nystatin 100000 units/ml 60ml [HHSC]

Facility

$78.34

Service Code	NDC 69315050460
Hospital Charge Code	2500594
Hospital Revenue Code	250
Min. Negotiated Rate	$39.17
Max. Negotiated Rate	$75.99
Rate for Payer: AlohaCare Medicaid	$39.17
Rate for Payer: AlohaCare Medicare	$39.17
Rate for Payer: Cash Price	$50.92
Rate for Payer: Devoted Health Medicare	$43.09
Rate for Payer: Hawaii Medical Service Association Medicare	$39.17
Rate for Payer: Hawaii Western Management Group Commercial	$74.42
Rate for Payer: Health Management Network Commercial	$66.59
Rate for Payer: Humana Medicare	$39.17
Rate for Payer: Kaiser Permanente Commercial	$70.51
Rate for Payer: Kaiser Permanente Medicaid	$39.95
Rate for Payer: Kaiser Permanente Medicare	$39.17
Rate for Payer: MDX Hawaii PPO	$75.99
Rate for Payer: Ohana Health Plan Medicaid	$39.17
Rate for Payer: Ohana Health Plan Medicare	$39.17
Rate for Payer: UnitedHealthcare Medicaid	$47.00
Rate for Payer: UnitedHealthcare Medicare	$39.17
Rate for Payer: University Health Alliance Commercial	$57.10

nystatin 100000 units/ml 60ml [HHSC]

Facility

$88.96

Service Code	NDC 60432053760
Hospital Charge Code	2500594
Hospital Revenue Code	250
Min. Negotiated Rate	$44.48
Max. Negotiated Rate	$86.29
Rate for Payer: AlohaCare Medicaid	$44.48
Rate for Payer: AlohaCare Medicare	$44.48
Rate for Payer: Cash Price	$57.82
Rate for Payer: Devoted Health Medicare	$48.93
Rate for Payer: Hawaii Medical Service Association Medicare	$44.48
Rate for Payer: Hawaii Western Management Group Commercial	$84.51
Rate for Payer: Health Management Network Commercial	$75.62
Rate for Payer: Humana Medicare	$44.48
Rate for Payer: Kaiser Permanente Commercial	$80.06
Rate for Payer: Kaiser Permanente Medicaid	$45.37
Rate for Payer: Kaiser Permanente Medicare	$44.48
Rate for Payer: MDX Hawaii PPO	$86.29
Rate for Payer: Ohana Health Plan Medicaid	$44.48
Rate for Payer: Ohana Health Plan Medicare	$44.48
Rate for Payer: UnitedHealthcare Medicaid	$53.38
Rate for Payer: UnitedHealthcare Medicare	$44.48
Rate for Payer: University Health Alliance Commercial	$64.84

nystatin 100K units/gm cream 30gm [HHSC]

Facility

$128.21

Service Code	NDC 51672128902
Hospital Charge Code	2500595
Hospital Revenue Code	250
Min. Negotiated Rate	$108.98
Max. Negotiated Rate	$124.36
Rate for Payer: Cash Price	$83.34
Rate for Payer: Health Management Network Commercial	$108.98
Rate for Payer: Kaiser Permanente Commercial	$115.39
Rate for Payer: MDX Hawaii PPO	$124.36

nystatin 100K units/gm cream 30gm [HHSC]

Facility

$127.88

Service Code	NDC 00713067831
Hospital Charge Code	2500595
Hospital Revenue Code	250
Min. Negotiated Rate	$108.70
Max. Negotiated Rate	$124.04
Rate for Payer: Cash Price	$83.12
Rate for Payer: Health Management Network Commercial	$108.70
Rate for Payer: Kaiser Permanente Commercial	$115.09
Rate for Payer: MDX Hawaii PPO	$124.04

nystatin 100K units/gm cream 30gm [HHSC]

Facility

$127.88

Service Code	NDC 00713067831
Hospital Charge Code	2500595
Hospital Revenue Code	250
Min. Negotiated Rate	$63.94
Max. Negotiated Rate	$124.04
Rate for Payer: AlohaCare Medicaid	$63.94
Rate for Payer: AlohaCare Medicare	$63.94
Rate for Payer: Cash Price	$83.12
Rate for Payer: Devoted Health Medicare	$70.33
Rate for Payer: Hawaii Medical Service Association Medicare	$63.94
Rate for Payer: Hawaii Western Management Group Commercial	$121.49
Rate for Payer: Health Management Network Commercial	$108.70
Rate for Payer: Humana Medicare	$63.94
Rate for Payer: Kaiser Permanente Commercial	$115.09
Rate for Payer: Kaiser Permanente Medicaid	$65.22
Rate for Payer: Kaiser Permanente Medicare	$63.94
Rate for Payer: MDX Hawaii PPO	$124.04
Rate for Payer: Ohana Health Plan Medicaid	$63.94
Rate for Payer: Ohana Health Plan Medicare	$63.94
Rate for Payer: UnitedHealthcare Medicaid	$76.73
Rate for Payer: UnitedHealthcare Medicare	$63.94
Rate for Payer: University Health Alliance Commercial	$93.21

nystatin 100K units/gm cream 30gm [HHSC]

Facility

$128.21

Service Code	NDC 51672128902
Hospital Charge Code	2500595
Hospital Revenue Code	250
Min. Negotiated Rate	$64.11
Max. Negotiated Rate	$124.36
Rate for Payer: AlohaCare Medicaid	$64.11
Rate for Payer: AlohaCare Medicare	$64.11
Rate for Payer: Cash Price	$83.34
Rate for Payer: Devoted Health Medicare	$70.52
Rate for Payer: Hawaii Medical Service Association Medicare	$64.11
Rate for Payer: Hawaii Western Management Group Commercial	$121.80
Rate for Payer: Health Management Network Commercial	$108.98
Rate for Payer: Humana Medicare	$64.11
Rate for Payer: Kaiser Permanente Commercial	$115.39
Rate for Payer: Kaiser Permanente Medicaid	$65.39
Rate for Payer: Kaiser Permanente Medicare	$64.11
Rate for Payer: MDX Hawaii PPO	$124.36
Rate for Payer: Ohana Health Plan Medicaid	$64.11
Rate for Payer: Ohana Health Plan Medicare	$64.11
Rate for Payer: UnitedHealthcare Medicaid	$76.93
Rate for Payer: UnitedHealthcare Medicare	$64.11
Rate for Payer: University Health Alliance Commercial	$93.45

nystatin-triamcinolone 30gm cream [HHSC]

Facility

$165.70

Service Code	NDC 45802088094
Hospital Charge Code	2500597
Hospital Revenue Code	250
Min. Negotiated Rate	$82.85
Max. Negotiated Rate	$160.73
Rate for Payer: AlohaCare Medicaid	$82.85
Rate for Payer: AlohaCare Medicare	$82.85
Rate for Payer: Cash Price	$107.70
Rate for Payer: Devoted Health Medicare	$91.14
Rate for Payer: Hawaii Medical Service Association Medicare	$82.85
Rate for Payer: Hawaii Western Management Group Commercial	$157.41
Rate for Payer: Health Management Network Commercial	$140.84
Rate for Payer: Humana Medicare	$82.85
Rate for Payer: Kaiser Permanente Commercial	$149.13
Rate for Payer: Kaiser Permanente Medicaid	$84.51
Rate for Payer: Kaiser Permanente Medicare	$82.85
Rate for Payer: MDX Hawaii PPO	$160.73
Rate for Payer: Ohana Health Plan Medicaid	$82.85
Rate for Payer: Ohana Health Plan Medicare	$82.85
Rate for Payer: UnitedHealthcare Medicaid	$99.42
Rate for Payer: UnitedHealthcare Medicare	$82.85
Rate for Payer: University Health Alliance Commercial	$120.78

nystatin-triamcinolone 30gm cream [HHSC]

Facility

$575.40

Service Code	NDC 68180054502
Hospital Charge Code	2500597
Hospital Revenue Code	250
Min. Negotiated Rate	$287.70
Max. Negotiated Rate	$558.14
Rate for Payer: AlohaCare Medicaid	$287.70
Rate for Payer: AlohaCare Medicare	$287.70
Rate for Payer: Cash Price	$374.01
Rate for Payer: Devoted Health Medicare	$316.47
Rate for Payer: Hawaii Medical Service Association Medicare	$287.70
Rate for Payer: Hawaii Western Management Group Commercial	$546.63
Rate for Payer: Health Management Network Commercial	$489.09
Rate for Payer: Humana Medicare	$287.70
Rate for Payer: Kaiser Permanente Commercial	$517.86
Rate for Payer: Kaiser Permanente Medicaid	$293.45
Rate for Payer: Kaiser Permanente Medicare	$287.70
Rate for Payer: MDX Hawaii PPO	$558.14
Rate for Payer: Ohana Health Plan Medicaid	$287.70
Rate for Payer: Ohana Health Plan Medicare	$287.70
Rate for Payer: UnitedHealthcare Medicaid	$345.24
Rate for Payer: UnitedHealthcare Medicare	$287.70
Rate for Payer: University Health Alliance Commercial	$419.41

nystatin-triamcinolone 30gm cream [HHSC]

Facility

$575.40

Service Code	NDC 68462031435
Hospital Charge Code	2500597
Hospital Revenue Code	250
Min. Negotiated Rate	$287.70
Max. Negotiated Rate	$558.14
Rate for Payer: AlohaCare Medicaid	$287.70
Rate for Payer: AlohaCare Medicare	$287.70
Rate for Payer: Cash Price	$374.01
Rate for Payer: Devoted Health Medicare	$316.47
Rate for Payer: Hawaii Medical Service Association Medicare	$287.70
Rate for Payer: Hawaii Western Management Group Commercial	$546.63
Rate for Payer: Health Management Network Commercial	$489.09
Rate for Payer: Humana Medicare	$287.70
Rate for Payer: Kaiser Permanente Commercial	$517.86
Rate for Payer: Kaiser Permanente Medicaid	$293.45
Rate for Payer: Kaiser Permanente Medicare	$287.70
Rate for Payer: MDX Hawaii PPO	$558.14
Rate for Payer: Ohana Health Plan Medicaid	$287.70
Rate for Payer: Ohana Health Plan Medicare	$287.70
Rate for Payer: UnitedHealthcare Medicaid	$345.24
Rate for Payer: UnitedHealthcare Medicare	$287.70
Rate for Payer: University Health Alliance Commercial	$419.41

nystatin-triamcinolone 30gm cream [HHSC]

Facility

$575.40

Service Code	NDC 68180054502
Hospital Charge Code	2500597
Hospital Revenue Code	250
Min. Negotiated Rate	$489.09
Max. Negotiated Rate	$558.14
Rate for Payer: Cash Price	$374.01
Rate for Payer: Health Management Network Commercial	$489.09
Rate for Payer: Kaiser Permanente Commercial	$517.86
Rate for Payer: MDX Hawaii PPO	$558.14

nystatin-triamcinolone 30gm cream [HHSC]

Facility

$575.40

Service Code	NDC 68462031435
Hospital Charge Code	2500597
Hospital Revenue Code	250
Min. Negotiated Rate	$489.09
Max. Negotiated Rate	$558.14
Rate for Payer: Cash Price	$374.01
Rate for Payer: Health Management Network Commercial	$489.09
Rate for Payer: Kaiser Permanente Commercial	$517.86
Rate for Payer: MDX Hawaii PPO	$558.14

nystatin-triamcinolone 30gm cream [HHSC]

Facility

$165.70

Service Code	NDC 45802088094
Hospital Charge Code	2500597
Hospital Revenue Code	250
Min. Negotiated Rate	$140.84
Max. Negotiated Rate	$160.73
Rate for Payer: Cash Price	$107.70
Rate for Payer: Health Management Network Commercial	$140.84
Rate for Payer: Kaiser Permanente Commercial	$149.13
Rate for Payer: MDX Hawaii PPO	$160.73

OASIS DRAIN, SINGLE W/AC 6/CS

Facility

$207.00

Hospital Charge Code	12115681
Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

OASIS DRAIN, SINGLE W/AC 6/CS

Facility

$207.00

Hospital Charge Code	12115681
Hospital Revenue Code	272
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
Rate for Payer: Hawaii Medical Service Association Medicare	$103.50
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$150.88

OB:AVALON CL FETAL AND MATERNAL PATCH

Facility

$218.00

Hospital Charge Code	11557654
Hospital Revenue Code	272
Min. Negotiated Rate	$109.00
Max. Negotiated Rate	$211.46
Rate for Payer: AlohaCare Medicaid	$109.00
Rate for Payer: AlohaCare Medicare	$109.00
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$119.90
Rate for Payer: Hawaii Medical Service Association Medicare	$109.00
Rate for Payer: Hawaii Western Management Group Commercial	$207.10
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Humana Medicare	$109.00
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: Kaiser Permanente Medicare	$109.00
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: Ohana Health Plan Medicaid	$109.00
Rate for Payer: Ohana Health Plan Medicare	$109.00
Rate for Payer: UnitedHealthcare Medicare	$109.00
Rate for Payer: University Health Alliance Commercial	$158.90

OB:AVALON CL FETAL AND MATERNAL PATCH

Facility

$218.00

Hospital Charge Code	11557654
Hospital Revenue Code	272
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: MDX Hawaii PPO	$211.46

OB Check Level 1 Charge

Facility

$346.00

Service Code	HCPCS 99211
Hospital Charge Code	8140428
Hospital Revenue Code	760
Min. Negotiated Rate	$9.17
Max. Negotiated Rate	$335.62
Rate for Payer: AlohaCare Medicaid	$173.00
Rate for Payer: AlohaCare Medicare	$173.00
Rate for Payer: Cash Price	$224.90
Rate for Payer: Cash Price	$224.90
Rate for Payer: Devoted Health Medicare	$190.30
Rate for Payer: Hawaii Medical Service Association Medicare	$173.00
Rate for Payer: Hawaii Western Management Group Commercial	$328.70
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Humana Medicare	$173.00
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: Kaiser Permanente Medicaid	$176.46
Rate for Payer: Kaiser Permanente Medicare	$173.00
Rate for Payer: MDX Hawaii PPO	$335.62
Rate for Payer: Ohana Health Plan Medicaid	$173.00
Rate for Payer: Ohana Health Plan Medicare	$173.00
Rate for Payer: UnitedHealthcare Medicaid	$9.17
Rate for Payer: UnitedHealthcare Medicare	$173.00
Rate for Payer: University Health Alliance Commercial	$252.20

OB Check Level 1 Charge

Facility

$346.00

Service Code	HCPCS 99211
Hospital Charge Code	8140428
Hospital Revenue Code	760
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

OB Check Level 2 Charge

Facility

$422.00

Service Code	HCPCS 99212
Hospital Charge Code	8140429
Hospital Revenue Code	760
Min. Negotiated Rate	$24.13
Max. Negotiated Rate	$409.34
Rate for Payer: AlohaCare Medicaid	$211.00
Rate for Payer: AlohaCare Medicare	$211.00
Rate for Payer: Cash Price	$274.30
Rate for Payer: Cash Price	$274.30
Rate for Payer: Devoted Health Medicare	$232.10
Rate for Payer: Hawaii Medical Service Association Medicare	$211.00
Rate for Payer: Hawaii Western Management Group Commercial	$400.90
Rate for Payer: Health Management Network Commercial	$358.70
Rate for Payer: Humana Medicare	$211.00
Rate for Payer: Kaiser Permanente Commercial	$379.80
Rate for Payer: Kaiser Permanente Medicaid	$215.22
Rate for Payer: Kaiser Permanente Medicare	$211.00
Rate for Payer: MDX Hawaii PPO	$409.34
Rate for Payer: Ohana Health Plan Medicaid	$211.00
Rate for Payer: Ohana Health Plan Medicare	$211.00
Rate for Payer: UnitedHealthcare Medicaid	$24.13
Rate for Payer: UnitedHealthcare Medicare	$211.00
Rate for Payer: University Health Alliance Commercial	$307.60

OB Check Level 2 Charge

Facility

$422.00

Service Code	HCPCS 99212
Hospital Charge Code	8140429
Hospital Revenue Code	760
Min. Negotiated Rate	$358.70
Max. Negotiated Rate	$409.34
Rate for Payer: Cash Price	$274.30
Rate for Payer: Health Management Network Commercial	$358.70
Rate for Payer: Kaiser Permanente Commercial	$379.80
Rate for Payer: MDX Hawaii PPO	$409.34

OB Check Level 3 Charge

Facility

$488.00

Service Code	HCPCS 99213
Hospital Charge Code	8140430
Hospital Revenue Code	760
Min. Negotiated Rate	$36.31
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
Rate for Payer: Hawaii Medical Service Association Medicare	$244.00
Rate for Payer: Hawaii Western Management Group Commercial	$463.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicaid	$36.31
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$355.70

OB Check Level 3 Charge

Facility

$488.00

Service Code	HCPCS 99213
Hospital Charge Code	8140430
Hospital Revenue Code	760
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

OB Check Level 4 Charge

Facility

$499.00

Service Code	HCPCS 99214
Hospital Charge Code	8140431
Hospital Revenue Code	760
Min. Negotiated Rate	$56.46
Max. Negotiated Rate	$484.03
Rate for Payer: AlohaCare Medicaid	$249.50
Rate for Payer: AlohaCare Medicare	$249.50
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$274.45
Rate for Payer: Hawaii Medical Service Association Medicare	$249.50
Rate for Payer: Hawaii Western Management Group Commercial	$474.05
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Humana Medicare	$249.50
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: Kaiser Permanente Medicaid	$254.49
Rate for Payer: Kaiser Permanente Medicare	$249.50
Rate for Payer: MDX Hawaii PPO	$484.03
Rate for Payer: Ohana Health Plan Medicaid	$249.50
Rate for Payer: Ohana Health Plan Medicare	$249.50
Rate for Payer: UnitedHealthcare Medicaid	$56.46
Rate for Payer: UnitedHealthcare Medicare	$249.50
Rate for Payer: University Health Alliance Commercial	$363.72

OB Check Level 4 Charge

Facility

$499.00

Service Code	HCPCS 99214
Hospital Charge Code	8140431
Hospital Revenue Code	760
Min. Negotiated Rate	$424.15
Max. Negotiated Rate	$484.03
Rate for Payer: Cash Price	$324.35
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$449.10
Rate for Payer: MDX Hawaii PPO	$484.03

Know your out-of-pocket cost for care.

All Charges