Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$35,362.95

Service Code	MSDRG 542
Min. Negotiated Rate	$35,362.95
Max. Negotiated Rate	$35,362.95
Rate for Payer: Hawaii Medical Service Association Commercial	$35,362.95

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$35,362.95

Service Code	MSDRG 544
Min. Negotiated Rate	$35,362.95
Max. Negotiated Rate	$35,362.95
Rate for Payer: Hawaii Medical Service Association Commercial	$35,362.95

PEAK FLOW METER CHARGE

Facility

$74.00

Service Code	HCPCS A4614
Hospital Charge Code	8243411
Hospital Revenue Code	272
Min. Negotiated Rate	$23.59
Max. Negotiated Rate	$71.78
Rate for Payer: AlohaCare Medicaid	$37.00
Rate for Payer: AlohaCare Medicare	$37.00
Rate for Payer: Cash Price	$48.10
Rate for Payer: Cash Price	$48.10
Rate for Payer: Devoted Health Medicare	$40.70
Rate for Payer: Hawaii Medical Service Association Medicare	$37.00
Rate for Payer: Hawaii Western Management Group Commercial	$70.30
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Humana Medicare	$37.00
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: Kaiser Permanente Medicaid	$37.74
Rate for Payer: Kaiser Permanente Medicare	$37.00
Rate for Payer: MDX Hawaii PPO	$71.78
Rate for Payer: Ohana Health Plan Medicaid	$37.00
Rate for Payer: Ohana Health Plan Medicare	$37.00
Rate for Payer: UnitedHealthcare Medicaid	$23.59
Rate for Payer: UnitedHealthcare Medicare	$37.00
Rate for Payer: University Health Alliance Commercial	$53.94

PEAK FLOW METER CHARGE

Facility

$74.00

Service Code	HCPCS A4614
Hospital Charge Code	8243411
Hospital Revenue Code	272
Min. Negotiated Rate	$62.90
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$48.10
Rate for Payer: Health Management Network Commercial	$62.90
Rate for Payer: Kaiser Permanente Commercial	$66.60
Rate for Payer: MDX Hawaii PPO	$71.78

.Ped Drugs Urine Panel FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395736
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

.Ped Drugs Urine Panel FSI

Facility

$1,384.00

Service Code	HCPCS 80307
Hospital Charge Code	8395736
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

PEG 3350 powder 17gm [HHSC]

Facility

$10.39

Service Code	NDC 00904642281
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$8.83
Max. Negotiated Rate	$10.08
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Management Network Commercial	$8.83
Rate for Payer: Kaiser Permanente Commercial	$9.35
Rate for Payer: MDX Hawaii PPO	$10.08

PEG 3350 powder 17gm [HHSC]

Facility

$6.36

Service Code	NDC 11523726808
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$6.17
Rate for Payer: Cash Price	$4.13
Rate for Payer: Health Management Network Commercial	$5.41
Rate for Payer: Kaiser Permanente Commercial	$5.72
Rate for Payer: MDX Hawaii PPO	$6.17

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 68084043098
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$13.15
Max. Negotiated Rate	$15.01
Rate for Payer: Cash Price	$10.06
Rate for Payer: Health Management Network Commercial	$13.15
Rate for Payer: Kaiser Permanente Commercial	$13.92
Rate for Payer: MDX Hawaii PPO	$15.01

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 60687043198
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$15.01
Rate for Payer: AlohaCare Medicaid	$7.74
Rate for Payer: AlohaCare Medicare	$7.74
Rate for Payer: Cash Price	$10.06
Rate for Payer: Devoted Health Medicare	$8.51
Rate for Payer: Hawaii Medical Service Association Medicare	$7.74
Rate for Payer: Hawaii Western Management Group Commercial	$14.70
Rate for Payer: Health Management Network Commercial	$13.15
Rate for Payer: Humana Medicare	$7.74
Rate for Payer: Kaiser Permanente Commercial	$13.92
Rate for Payer: Kaiser Permanente Medicaid	$7.89
Rate for Payer: Kaiser Permanente Medicare	$7.74
Rate for Payer: MDX Hawaii PPO	$15.01
Rate for Payer: Ohana Health Plan Medicaid	$7.74
Rate for Payer: Ohana Health Plan Medicare	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$9.28
Rate for Payer: UnitedHealthcare Medicare	$7.74
Rate for Payer: University Health Alliance Commercial	$11.28

PEG 3350 powder 17gm [HHSC]

Facility

$6.36

Service Code	NDC 11523726808
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$6.17
Rate for Payer: AlohaCare Medicaid	$3.18
Rate for Payer: AlohaCare Medicare	$3.18
Rate for Payer: Cash Price	$4.13
Rate for Payer: Devoted Health Medicare	$3.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3.18
Rate for Payer: Hawaii Western Management Group Commercial	$6.04
Rate for Payer: Health Management Network Commercial	$5.41
Rate for Payer: Humana Medicare	$3.18
Rate for Payer: Kaiser Permanente Commercial	$5.72
Rate for Payer: Kaiser Permanente Medicaid	$3.24
Rate for Payer: Kaiser Permanente Medicare	$3.18
Rate for Payer: MDX Hawaii PPO	$6.17
Rate for Payer: Ohana Health Plan Medicaid	$3.18
Rate for Payer: Ohana Health Plan Medicare	$3.18
Rate for Payer: UnitedHealthcare Medicaid	$3.82
Rate for Payer: UnitedHealthcare Medicare	$3.18
Rate for Payer: University Health Alliance Commercial	$4.64

PEG 3350 powder 17gm [HHSC]

Facility

$5.46

Service Code	NDC 11523726803
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$5.30
Rate for Payer: AlohaCare Medicaid	$2.73
Rate for Payer: AlohaCare Medicare	$2.73
Rate for Payer: Cash Price	$3.55
Rate for Payer: Devoted Health Medicare	$3.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2.73
Rate for Payer: Hawaii Western Management Group Commercial	$5.19
Rate for Payer: Health Management Network Commercial	$4.64
Rate for Payer: Humana Medicare	$2.73
Rate for Payer: Kaiser Permanente Commercial	$4.91
Rate for Payer: Kaiser Permanente Medicaid	$2.78
Rate for Payer: Kaiser Permanente Medicare	$2.73
Rate for Payer: MDX Hawaii PPO	$5.30
Rate for Payer: Ohana Health Plan Medicaid	$2.73
Rate for Payer: Ohana Health Plan Medicare	$2.73
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: UnitedHealthcare Medicare	$2.73
Rate for Payer: University Health Alliance Commercial	$3.98

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 60687043198
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$13.15
Max. Negotiated Rate	$15.01
Rate for Payer: Cash Price	$10.06
Rate for Payer: Health Management Network Commercial	$13.15
Rate for Payer: Kaiser Permanente Commercial	$13.92
Rate for Payer: MDX Hawaii PPO	$15.01

PEG 3350 powder 17gm [HHSC]

Facility

$9.76

Service Code	NDC 60687043127
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$9.47
Rate for Payer: AlohaCare Medicaid	$4.88
Rate for Payer: AlohaCare Medicare	$4.88
Rate for Payer: Cash Price	$6.34
Rate for Payer: Devoted Health Medicare	$5.37
Rate for Payer: Hawaii Medical Service Association Medicare	$4.88
Rate for Payer: Hawaii Western Management Group Commercial	$9.27
Rate for Payer: Health Management Network Commercial	$8.30
Rate for Payer: Humana Medicare	$4.88
Rate for Payer: Kaiser Permanente Commercial	$8.78
Rate for Payer: Kaiser Permanente Medicaid	$4.98
Rate for Payer: Kaiser Permanente Medicare	$4.88
Rate for Payer: MDX Hawaii PPO	$9.47
Rate for Payer: Ohana Health Plan Medicaid	$4.88
Rate for Payer: Ohana Health Plan Medicare	$4.88
Rate for Payer: UnitedHealthcare Medicaid	$5.86
Rate for Payer: UnitedHealthcare Medicare	$4.88
Rate for Payer: University Health Alliance Commercial	$7.11

PEG 3350 powder 17gm [HHSC]

Facility

$9.76

Service Code	NDC 60687043127
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$9.47
Rate for Payer: Cash Price	$6.34
Rate for Payer: Health Management Network Commercial	$8.30
Rate for Payer: Kaiser Permanente Commercial	$8.78
Rate for Payer: MDX Hawaii PPO	$9.47

PEG 3350 powder 17gm [HHSC]

Facility

$5.46

Service Code	NDC 11523726803
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$5.30
Rate for Payer: Cash Price	$3.55
Rate for Payer: Health Management Network Commercial	$4.64
Rate for Payer: Kaiser Permanente Commercial	$4.91
Rate for Payer: MDX Hawaii PPO	$5.30

PEG 3350 powder 17gm [HHSC]

Facility

$10.39

Service Code	NDC 00904642281
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$10.08
Rate for Payer: AlohaCare Medicaid	$5.20
Rate for Payer: AlohaCare Medicare	$5.20
Rate for Payer: Cash Price	$6.75
Rate for Payer: Devoted Health Medicare	$5.71
Rate for Payer: Hawaii Medical Service Association Medicare	$5.20
Rate for Payer: Hawaii Western Management Group Commercial	$9.87
Rate for Payer: Health Management Network Commercial	$8.83
Rate for Payer: Humana Medicare	$5.20
Rate for Payer: Kaiser Permanente Commercial	$9.35
Rate for Payer: Kaiser Permanente Medicaid	$5.30
Rate for Payer: Kaiser Permanente Medicare	$5.20
Rate for Payer: MDX Hawaii PPO	$10.08
Rate for Payer: Ohana Health Plan Medicaid	$5.20
Rate for Payer: Ohana Health Plan Medicare	$5.20
Rate for Payer: UnitedHealthcare Medicaid	$6.23
Rate for Payer: UnitedHealthcare Medicare	$5.20
Rate for Payer: University Health Alliance Commercial	$7.57

PEG 3350 powder 17gm [HHSC]

Facility

$15.47

Service Code	NDC 68084043098
Hospital Charge Code	2500671
Hospital Revenue Code	250
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$15.01
Rate for Payer: AlohaCare Medicaid	$7.74
Rate for Payer: AlohaCare Medicare	$7.74
Rate for Payer: Cash Price	$10.06
Rate for Payer: Devoted Health Medicare	$8.51
Rate for Payer: Hawaii Medical Service Association Medicare	$7.74
Rate for Payer: Hawaii Western Management Group Commercial	$14.70
Rate for Payer: Health Management Network Commercial	$13.15
Rate for Payer: Humana Medicare	$7.74
Rate for Payer: Kaiser Permanente Commercial	$13.92
Rate for Payer: Kaiser Permanente Medicaid	$7.89
Rate for Payer: Kaiser Permanente Medicare	$7.74
Rate for Payer: MDX Hawaii PPO	$15.01
Rate for Payer: Ohana Health Plan Medicaid	$7.74
Rate for Payer: Ohana Health Plan Medicare	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$9.28
Rate for Payer: UnitedHealthcare Medicare	$7.74
Rate for Payer: University Health Alliance Commercial	$11.28

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$42,476.34

Service Code	MSDRG 734
Min. Negotiated Rate	$42,476.34
Max. Negotiated Rate	$42,476.34
Rate for Payer: Hawaii Medical Service Association Commercial	$42,476.34

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$42,476.34

Service Code	MSDRG 735
Min. Negotiated Rate	$42,476.34
Max. Negotiated Rate	$42,476.34
Rate for Payer: Hawaii Medical Service Association Commercial	$42,476.34

penicillin G benzathine 1200000 unit/2 ml syringe [HHSC]

Facility

$1,167.54

Service Code	HCPCS J0561
Hospital Charge Code	2500638
Hospital Revenue Code	636
Min. Negotiated Rate	$29.30
Max. Negotiated Rate	$1,132.51
Rate for Payer: AlohaCare Medicaid	$583.77
Rate for Payer: AlohaCare Medicare	$583.77
Rate for Payer: Cash Price	$758.90
Rate for Payer: Cash Price	$758.90
Rate for Payer: Devoted Health Medicare	$642.15
Rate for Payer: Hawaii Medical Service Association ABD	$29.30
Rate for Payer: Hawaii Medical Service Association Commercial	$39.34
Rate for Payer: Hawaii Medical Service Association Medicare	$583.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,109.16
Rate for Payer: Health Management Network Commercial	$992.41
Rate for Payer: Humana Medicare	$583.77
Rate for Payer: Kaiser Permanente Commercial	$1,050.79
Rate for Payer: Kaiser Permanente Medicaid	$595.45
Rate for Payer: Kaiser Permanente Medicare	$583.77
Rate for Payer: MDX Hawaii PPO	$1,132.51
Rate for Payer: Ohana Health Plan Medicaid	$583.77
Rate for Payer: Ohana Health Plan Medicare	$583.77
Rate for Payer: UnitedHealthcare Medicaid	$700.52
Rate for Payer: UnitedHealthcare Medicare	$583.77
Rate for Payer: University Health Alliance Commercial	$851.02

penicillin G benzathine 1200000 unit/2 ml syringe [HHSC]

Facility

$1,167.54

Service Code	HCPCS J0561
Hospital Charge Code	2500638
Hospital Revenue Code	250
Min. Negotiated Rate	$992.41
Max. Negotiated Rate	$1,132.51
Rate for Payer: Cash Price	$758.90
Rate for Payer: Health Management Network Commercial	$992.41
Rate for Payer: Kaiser Permanente Commercial	$1,050.79
Rate for Payer: MDX Hawaii PPO	$1,132.51

penicillin GK 5000000 unit vial [HHSC]

Facility

$81.60

Service Code	HCPCS J2540
Hospital Charge Code	2500639
Hospital Revenue Code	250
Min. Negotiated Rate	$69.36
Max. Negotiated Rate	$79.15
Rate for Payer: Cash Price	$53.04
Rate for Payer: Cash Price	$58.34
Rate for Payer: Health Management Network Commercial	$69.36
Rate for Payer: Health Management Network Commercial	$76.30
Rate for Payer: Kaiser Permanente Commercial	$73.44
Rate for Payer: Kaiser Permanente Commercial	$80.78
Rate for Payer: MDX Hawaii PPO	$87.07
Rate for Payer: MDX Hawaii PPO	$79.15

penicillin GK 5000000 unit vial [HHSC]

Facility

$81.60

Service Code	HCPCS J2540
Hospital Charge Code	2500639
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$79.15
Rate for Payer: AlohaCare Medicaid	$40.80
Rate for Payer: AlohaCare Medicaid	$44.88
Rate for Payer: AlohaCare Medicare	$44.88
Rate for Payer: AlohaCare Medicare	$40.80
Rate for Payer: Cash Price	$58.34
Rate for Payer: Cash Price	$53.04
Rate for Payer: Cash Price	$53.04
Rate for Payer: Cash Price	$58.34
Rate for Payer: Devoted Health Medicare	$44.88
Rate for Payer: Devoted Health Medicare	$49.37
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Medicare	$44.88
Rate for Payer: Hawaii Medical Service Association Medicare	$40.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$77.52
Rate for Payer: Hawaii Western Management Group Commercial	$85.27
Rate for Payer: Health Management Network Commercial	$76.30
Rate for Payer: Health Management Network Commercial	$69.36
Rate for Payer: Humana Medicare	$40.80
Rate for Payer: Humana Medicare	$44.88
Rate for Payer: Kaiser Permanente Commercial	$73.44
Rate for Payer: Kaiser Permanente Commercial	$80.78
Rate for Payer: Kaiser Permanente Medicaid	$45.78
Rate for Payer: Kaiser Permanente Medicaid	$41.62
Rate for Payer: Kaiser Permanente Medicare	$40.80
Rate for Payer: Kaiser Permanente Medicare	$44.88
Rate for Payer: MDX Hawaii PPO	$79.15
Rate for Payer: MDX Hawaii PPO	$87.07
Rate for Payer: Ohana Health Plan Medicaid	$44.88
Rate for Payer: Ohana Health Plan Medicaid	$40.80
Rate for Payer: Ohana Health Plan Medicare	$40.80
Rate for Payer: Ohana Health Plan Medicare	$44.88
Rate for Payer: UnitedHealthcare Medicaid	$53.86
Rate for Payer: UnitedHealthcare Medicaid	$48.96
Rate for Payer: UnitedHealthcare Medicare	$40.80
Rate for Payer: UnitedHealthcare Medicare	$44.88
Rate for Payer: University Health Alliance Commercial	$59.48
Rate for Payer: University Health Alliance Commercial	$65.43

penicillin VK 500 mg tablet [HHSC]

Facility

$4.32

Service Code	NDC 57237004101
Hospital Charge Code	2500641
Hospital Revenue Code	250
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$4.19
Rate for Payer: AlohaCare Medicaid	$2.16
Rate for Payer: AlohaCare Medicare	$2.16
Rate for Payer: Cash Price	$2.81
Rate for Payer: Devoted Health Medicare	$2.38
Rate for Payer: Hawaii Medical Service Association Medicare	$2.16
Rate for Payer: Hawaii Western Management Group Commercial	$4.10
Rate for Payer: Health Management Network Commercial	$3.67
Rate for Payer: Humana Medicare	$2.16
Rate for Payer: Kaiser Permanente Commercial	$3.89
Rate for Payer: Kaiser Permanente Medicaid	$2.20
Rate for Payer: Kaiser Permanente Medicare	$2.16
Rate for Payer: MDX Hawaii PPO	$4.19
Rate for Payer: Ohana Health Plan Medicaid	$2.16
Rate for Payer: Ohana Health Plan Medicare	$2.16
Rate for Payer: UnitedHealthcare Medicaid	$2.59
Rate for Payer: UnitedHealthcare Medicare	$2.16
Rate for Payer: University Health Alliance Commercial	$3.15

Know your out-of-pocket cost for care.

All Charges