Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

pantoprazole DR 40 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 66993006880
Hospital Charge Code	2500634
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

pantoprazole DR 40 mg tablet [HHSC]

Facility

$22.39

Service Code	NDC 50268063915
Hospital Charge Code	2500634
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$21.72
Rate for Payer: AlohaCare Medicaid	$11.20
Rate for Payer: AlohaCare Medicare	$11.20
Rate for Payer: Cash Price	$14.55
Rate for Payer: Devoted Health Medicare	$12.31
Rate for Payer: Hawaii Medical Service Association Medicare	$11.20
Rate for Payer: Hawaii Western Management Group Commercial	$21.27
Rate for Payer: Health Management Network Commercial	$19.03
Rate for Payer: Humana Medicare	$11.20
Rate for Payer: Kaiser Permanente Commercial	$20.15
Rate for Payer: Kaiser Permanente Medicaid	$11.42
Rate for Payer: Kaiser Permanente Medicare	$11.20
Rate for Payer: MDX Hawaii PPO	$21.72
Rate for Payer: Ohana Health Plan Medicaid	$11.20
Rate for Payer: Ohana Health Plan Medicare	$11.20
Rate for Payer: UnitedHealthcare Medicaid	$13.43
Rate for Payer: UnitedHealthcare Medicare	$11.20
Rate for Payer: University Health Alliance Commercial	$16.32

pantoprazole DR 40 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687073609
Hospital Charge Code	2500634
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

pantoprazole DR 40 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084081309
Hospital Charge Code	2500634
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

pantoprazole DR 40 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084081309
Hospital Charge Code	2500634
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

pantoprazole DR 40 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687073665
Hospital Charge Code	2500634
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

Paracentesis w/ Imaging

Professional

Both

$3,755.00

Service Code	HCPCS 49083
Hospital Charge Code	11964775
Hospital Revenue Code	975
Min. Negotiated Rate	$92.74
Max. Negotiated Rate	$3,191.75
Rate for Payer: AlohaCare Medicaid	$105.50
Rate for Payer: AlohaCare Medicare	$92.74
Rate for Payer: Cash Price	$2,440.75
Rate for Payer: Cash Price	$2,440.75
Rate for Payer: Devoted Health Medicare	$102.01
Rate for Payer: Hawaii Medical Service Association ABD	$105.50
Rate for Payer: Hawaii Medical Service Association Commercial	$177.92
Rate for Payer: Hawaii Medical Service Association Medicare	$92.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$105.50
Rate for Payer: Health Management Network Commercial	$3,191.75
Rate for Payer: Kaiser Permanente Commercial	$102.01
Rate for Payer: Kaiser Permanente Medicaid	$102.01
Rate for Payer: Kaiser Permanente Medicare	$102.01
Rate for Payer: Ohana Health Plan Medicaid	$105.50
Rate for Payer: Ohana Health Plan Medicare	$92.74
Rate for Payer: UnitedHealthcare Medicaid	$105.50
Rate for Payer: UnitedHealthcare Medicare	$92.74
Rate for Payer: University Health Alliance Commercial	$140.13

Paracentesis w/o Imaging

Professional

Both

$2,018.00

Service Code	HCPCS 49082
Hospital Charge Code	11966109
Hospital Revenue Code	975
Min. Negotiated Rate	$71.63
Max. Negotiated Rate	$1,715.30
Rate for Payer: AlohaCare Medicaid	$73.51
Rate for Payer: AlohaCare Medicare	$71.63
Rate for Payer: Cash Price	$1,311.70
Rate for Payer: Cash Price	$1,311.70
Rate for Payer: Devoted Health Medicare	$78.79
Rate for Payer: Hawaii Medical Service Association ABD	$73.51
Rate for Payer: Hawaii Medical Service Association Commercial	$123.60
Rate for Payer: Hawaii Medical Service Association Medicare	$71.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$73.51
Rate for Payer: Hawaii Western Management Group Commercial	$214.76
Rate for Payer: Health Management Network Commercial	$1,715.30
Rate for Payer: Kaiser Permanente Commercial	$78.79
Rate for Payer: Kaiser Permanente Medicaid	$78.79
Rate for Payer: Kaiser Permanente Medicare	$78.79
Rate for Payer: Ohana Health Plan Medicaid	$73.51
Rate for Payer: Ohana Health Plan Medicare	$71.63
Rate for Payer: UnitedHealthcare Medicaid	$73.51
Rate for Payer: UnitedHealthcare Medicare	$71.63

Paraffin Bath Charge

Facility

$55.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	8111699
Hospital Revenue Code	420
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Western Management Group Commercial	$52.25
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$40.09

Paraffin Bath Charge

Facility

$56.00

Service Code	HCPCS 97018 GP,CQ
Hospital Charge Code	8123831
Hospital Revenue Code	430
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$40.82

Paraffin Bath Charge

Facility

$55.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	8111699
Hospital Revenue Code	420
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

Paraffin Bath Charge

Facility

$56.00

Service Code	HCPCS 97018 GP,CQ
Hospital Charge Code	8123831
Hospital Revenue Code	430
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

Parasite Macroscopic Exam

Facility

$53.00

Service Code	HCPCS 87169
Hospital Charge Code	8878773
Hospital Revenue Code	306
Min. Negotiated Rate	$45.05
Max. Negotiated Rate	$51.41
Rate for Payer: Cash Price	$34.45
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Kaiser Permanente Commercial	$47.70
Rate for Payer: MDX Hawaii PPO	$51.41

Parasite Macroscopic Exam

Facility

$53.00

Service Code	HCPCS 87169
Hospital Charge Code	8878773
Hospital Revenue Code	306
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$51.41
Rate for Payer: AlohaCare Medicaid	$26.50
Rate for Payer: AlohaCare Medicare	$26.50
Rate for Payer: Cash Price	$34.45
Rate for Payer: Cash Price	$34.45
Rate for Payer: Devoted Health Medicare	$29.15
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.39
Rate for Payer: Hawaii Medical Service Association Medicare	$26.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.31
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Humana Medicare	$26.50
Rate for Payer: Kaiser Permanente Commercial	$47.70
Rate for Payer: Kaiser Permanente Medicaid	$27.03
Rate for Payer: Kaiser Permanente Medicare	$26.50
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: Ohana Health Plan Medicaid	$26.50
Rate for Payer: Ohana Health Plan Medicare	$26.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$26.50
Rate for Payer: University Health Alliance Commercial	$11.03

Parathyroid Hormone (PTH) Intact Molecule FSI

Facility

$461.00

Service Code	HCPCS 83970
Hospital Charge Code	8118009
Hospital Revenue Code	301
Min. Negotiated Rate	$41.28
Max. Negotiated Rate	$447.17
Rate for Payer: AlohaCare Medicaid	$230.50
Rate for Payer: AlohaCare Medicare	$230.50
Rate for Payer: Cash Price	$299.65
Rate for Payer: Cash Price	$299.65
Rate for Payer: Devoted Health Medicare	$253.55
Rate for Payer: Hawaii Medical Service Association ABD	$57.04
Rate for Payer: Hawaii Medical Service Association Commercial	$51.60
Rate for Payer: Hawaii Medical Service Association Medicare	$230.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.89
Rate for Payer: Hawaii Western Management Group Commercial	$41.28
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Humana Medicare	$230.50
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: Kaiser Permanente Medicaid	$235.11
Rate for Payer: Kaiser Permanente Medicare	$230.50
Rate for Payer: MDX Hawaii PPO	$447.17
Rate for Payer: Ohana Health Plan Medicaid	$230.50
Rate for Payer: Ohana Health Plan Medicare	$230.50
Rate for Payer: UnitedHealthcare Medicaid	$57.04
Rate for Payer: UnitedHealthcare Medicare	$230.50
Rate for Payer: University Health Alliance Commercial	$106.69

Parathyroid Hormone (PTH) Intact Molecule FSI

Facility

$461.00

Service Code	HCPCS 83970
Hospital Charge Code	8118009
Hospital Revenue Code	301
Min. Negotiated Rate	$391.85
Max. Negotiated Rate	$447.17
Rate for Payer: Cash Price	$299.65
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: MDX Hawaii PPO	$447.17

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE

Facility

$5,655.00

Service Code	CPT 28124
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,655.00
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS

Facility

$6,743.44

Service Code	CPT 28122
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$1,030.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$6,743.44

Parvovirus B19, IgG, IgM FSI

Facility

$241.00

Service Code	HCPCS 86747
Hospital Charge Code	8118010
Hospital Revenue Code	300
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$156.65
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: MDX Hawaii PPO	$233.77

Parvovirus B19, IgG, IgM FSI

Facility

$241.00

Service Code	HCPCS 86747
Hospital Charge Code	8118010
Hospital Revenue Code	300
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$233.77
Rate for Payer: AlohaCare Medicaid	$120.50
Rate for Payer: AlohaCare Medicare	$120.50
Rate for Payer: Cash Price	$156.65
Rate for Payer: Cash Price	$156.65
Rate for Payer: Devoted Health Medicare	$132.55
Rate for Payer: Hawaii Medical Service Association ABD	$20.77
Rate for Payer: Hawaii Medical Service Association Commercial	$18.79
Rate for Payer: Hawaii Medical Service Association Medicare	$120.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.81
Rate for Payer: Hawaii Western Management Group Commercial	$15.03
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Humana Medicare	$120.50
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: Kaiser Permanente Medicaid	$122.91
Rate for Payer: Kaiser Permanente Medicare	$120.50
Rate for Payer: MDX Hawaii PPO	$233.77
Rate for Payer: Ohana Health Plan Medicaid	$120.50
Rate for Payer: Ohana Health Plan Medicare	$120.50
Rate for Payer: UnitedHealthcare Medicaid	$20.77
Rate for Payer: UnitedHealthcare Medicare	$120.50
Rate for Payer: University Health Alliance Commercial	$38.85

Parvovirus B19, IgM FSI

Facility

$172.00

Service Code	HCPCS 86747
Hospital Charge Code	8118011
Hospital Revenue Code	302
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$166.84
Rate for Payer: AlohaCare Medicaid	$86.00
Rate for Payer: AlohaCare Medicare	$86.00
Rate for Payer: Cash Price	$111.80
Rate for Payer: Cash Price	$111.80
Rate for Payer: Devoted Health Medicare	$94.60
Rate for Payer: Hawaii Medical Service Association ABD	$20.77
Rate for Payer: Hawaii Medical Service Association Commercial	$18.79
Rate for Payer: Hawaii Medical Service Association Medicare	$86.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.81
Rate for Payer: Hawaii Western Management Group Commercial	$15.03
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Humana Medicare	$86.00
Rate for Payer: Kaiser Permanente Commercial	$154.80
Rate for Payer: Kaiser Permanente Medicaid	$87.72
Rate for Payer: Kaiser Permanente Medicare	$86.00
Rate for Payer: MDX Hawaii PPO	$166.84
Rate for Payer: Ohana Health Plan Medicaid	$86.00
Rate for Payer: Ohana Health Plan Medicare	$86.00
Rate for Payer: UnitedHealthcare Medicaid	$20.77
Rate for Payer: UnitedHealthcare Medicare	$86.00
Rate for Payer: University Health Alliance Commercial	$38.85

Parvovirus B19, IgM FSI

Facility

$172.00

Service Code	HCPCS 86747
Hospital Charge Code	8118011
Hospital Revenue Code	302
Min. Negotiated Rate	$146.20
Max. Negotiated Rate	$166.84
Rate for Payer: Cash Price	$111.80
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Kaiser Permanente Commercial	$154.80
Rate for Payer: MDX Hawaii PPO	$166.84

PATCH, HERNIA AUTOSUTURE ABSORBATACK

Facility

$2,709.00

Hospital Charge Code	8274184
Hospital Revenue Code	272
Min. Negotiated Rate	$1,354.50
Max. Negotiated Rate	$2,627.73
Rate for Payer: AlohaCare Medicaid	$1,354.50
Rate for Payer: AlohaCare Medicare	$1,354.50
Rate for Payer: Cash Price	$1,760.85
Rate for Payer: Devoted Health Medicare	$1,489.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1,354.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,573.55
Rate for Payer: Health Management Network Commercial	$2,302.65
Rate for Payer: Humana Medicare	$1,354.50
Rate for Payer: Kaiser Permanente Commercial	$2,438.10
Rate for Payer: Kaiser Permanente Medicaid	$1,381.59
Rate for Payer: Kaiser Permanente Medicare	$1,354.50
Rate for Payer: MDX Hawaii PPO	$2,627.73
Rate for Payer: Ohana Health Plan Medicaid	$1,354.50
Rate for Payer: Ohana Health Plan Medicare	$1,354.50
Rate for Payer: UnitedHealthcare Medicare	$1,354.50
Rate for Payer: University Health Alliance Commercial	$1,974.59

PATCH, HERNIA AUTOSUTURE ABSORBATACK

Facility

$2,709.00

Hospital Charge Code	8274184
Hospital Revenue Code	272
Min. Negotiated Rate	$2,302.65
Max. Negotiated Rate	$2,627.73
Rate for Payer: Cash Price	$1,760.85
Rate for Payer: Health Management Network Commercial	$2,302.65
Rate for Payer: Kaiser Permanente Commercial	$2,438.10
Rate for Payer: MDX Hawaii PPO	$2,627.73

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$35,362.95

Service Code	MSDRG 543
Min. Negotiated Rate	$35,362.95
Max. Negotiated Rate	$35,362.95
Rate for Payer: Hawaii Medical Service Association Commercial	$35,362.95

Know your out-of-pocket cost for care.

All Charges