Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PERITONEAL ADHESIOLYSIS WITH MCC

Facility

$64,989.30

Service Code	MSDRG 335
Min. Negotiated Rate	$64,989.30
Max. Negotiated Rate	$64,989.30
Rate for Payer: Hawaii Medical Service Association Commercial	$64,989.30

PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC

Facility

$35,260.97

Service Code	MSDRG 337
Min. Negotiated Rate	$35,260.97
Max. Negotiated Rate	$35,260.97
Rate for Payer: Hawaii Medical Service Association Commercial	$35,260.97

PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC

Facility

$57,569.97

Service Code	MSDRG 243
Min. Negotiated Rate	$57,569.97
Max. Negotiated Rate	$57,569.97
Rate for Payer: Hawaii Medical Service Association Commercial	$57,569.97

PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC

Facility

$76,997.92

Service Code	MSDRG 242
Min. Negotiated Rate	$76,997.92
Max. Negotiated Rate	$76,997.92
Rate for Payer: Hawaii Medical Service Association Commercial	$76,997.92

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC

Facility

$47,295.08

Service Code	MSDRG 244
Min. Negotiated Rate	$47,295.08
Max. Negotiated Rate	$47,295.08
Rate for Payer: Hawaii Medical Service Association Commercial	$47,295.08

permethrin 1% 60 ml lotion [HHSC]

Facility

$61.25

Service Code	HCPCS A9270
Hospital Charge Code	2500995
Hospital Revenue Code	250
Min. Negotiated Rate	$52.06
Max. Negotiated Rate	$59.41
Rate for Payer: Cash Price	$39.81
Rate for Payer: Cash Price	$38.20
Rate for Payer: Health Management Network Commercial	$49.95
Rate for Payer: Health Management Network Commercial	$52.06
Rate for Payer: Kaiser Permanente Commercial	$52.89
Rate for Payer: Kaiser Permanente Commercial	$55.12
Rate for Payer: MDX Hawaii PPO	$59.41
Rate for Payer: MDX Hawaii PPO	$57.01

permethrin 1% 60 ml lotion [HHSC]

Facility

$61.25

Service Code	HCPCS A9270
Hospital Charge Code	2500995
Hospital Revenue Code	637
Min. Negotiated Rate	$30.62
Max. Negotiated Rate	$59.41
Rate for Payer: AlohaCare Medicaid	$30.62
Rate for Payer: AlohaCare Medicaid	$29.39
Rate for Payer: AlohaCare Medicare	$29.39
Rate for Payer: AlohaCare Medicare	$30.62
Rate for Payer: Cash Price	$38.20
Rate for Payer: Cash Price	$39.81
Rate for Payer: Devoted Health Medicare	$32.32
Rate for Payer: Devoted Health Medicare	$33.69
Rate for Payer: Hawaii Medical Service Association Medicare	$30.62
Rate for Payer: Hawaii Medical Service Association Medicare	$29.39
Rate for Payer: Hawaii Western Management Group Commercial	$58.19
Rate for Payer: Hawaii Western Management Group Commercial	$55.83
Rate for Payer: Health Management Network Commercial	$49.95
Rate for Payer: Health Management Network Commercial	$52.06
Rate for Payer: Humana Medicare	$29.39
Rate for Payer: Humana Medicare	$30.62
Rate for Payer: Kaiser Permanente Commercial	$52.89
Rate for Payer: Kaiser Permanente Commercial	$55.12
Rate for Payer: Kaiser Permanente Medicaid	$29.97
Rate for Payer: Kaiser Permanente Medicaid	$31.24
Rate for Payer: Kaiser Permanente Medicare	$30.62
Rate for Payer: Kaiser Permanente Medicare	$29.39
Rate for Payer: MDX Hawaii PPO	$59.41
Rate for Payer: MDX Hawaii PPO	$57.01
Rate for Payer: Ohana Health Plan Medicaid	$29.39
Rate for Payer: Ohana Health Plan Medicaid	$30.62
Rate for Payer: Ohana Health Plan Medicare	$29.39
Rate for Payer: Ohana Health Plan Medicare	$30.62
Rate for Payer: UnitedHealthcare Medicare	$29.39
Rate for Payer: UnitedHealthcare Medicare	$30.62
Rate for Payer: University Health Alliance Commercial	$42.84
Rate for Payer: University Health Alliance Commercial	$44.65

permethrin 5% cream topical [HHSC]

Facility

$500.64

Service Code	NDC 00472024260
Hospital Charge Code	2500643
Hospital Revenue Code	250
Min. Negotiated Rate	$425.54
Max. Negotiated Rate	$485.62
Rate for Payer: Cash Price	$325.42
Rate for Payer: Health Management Network Commercial	$425.54
Rate for Payer: Kaiser Permanente Commercial	$450.58
Rate for Payer: MDX Hawaii PPO	$485.62

permethrin 5% cream topical [HHSC]

Facility

$488.62

Service Code	NDC 21922002107
Hospital Charge Code	2500643
Hospital Revenue Code	250
Min. Negotiated Rate	$244.31
Max. Negotiated Rate	$473.96
Rate for Payer: AlohaCare Medicaid	$244.31
Rate for Payer: AlohaCare Medicare	$244.31
Rate for Payer: Cash Price	$317.60
Rate for Payer: Devoted Health Medicare	$268.74
Rate for Payer: Hawaii Medical Service Association Medicare	$244.31
Rate for Payer: Hawaii Western Management Group Commercial	$464.19
Rate for Payer: Health Management Network Commercial	$415.33
Rate for Payer: Humana Medicare	$244.31
Rate for Payer: Kaiser Permanente Commercial	$439.76
Rate for Payer: Kaiser Permanente Medicaid	$249.20
Rate for Payer: Kaiser Permanente Medicare	$244.31
Rate for Payer: MDX Hawaii PPO	$473.96
Rate for Payer: Ohana Health Plan Medicaid	$244.31
Rate for Payer: Ohana Health Plan Medicare	$244.31
Rate for Payer: UnitedHealthcare Medicaid	$293.17
Rate for Payer: UnitedHealthcare Medicare	$244.31
Rate for Payer: University Health Alliance Commercial	$356.16

permethrin 5% cream topical [HHSC]

Facility

$488.62

Service Code	NDC 21922002107
Hospital Charge Code	2500643
Hospital Revenue Code	250
Min. Negotiated Rate	$415.33
Max. Negotiated Rate	$473.96
Rate for Payer: Cash Price	$317.60
Rate for Payer: Health Management Network Commercial	$415.33
Rate for Payer: Kaiser Permanente Commercial	$439.76
Rate for Payer: MDX Hawaii PPO	$473.96

permethrin 5% cream topical [HHSC]

Facility

$500.64

Service Code	NDC 00472024260
Hospital Charge Code	2500643
Hospital Revenue Code	250
Min. Negotiated Rate	$250.32
Max. Negotiated Rate	$485.62
Rate for Payer: AlohaCare Medicaid	$250.32
Rate for Payer: AlohaCare Medicare	$250.32
Rate for Payer: Cash Price	$325.42
Rate for Payer: Devoted Health Medicare	$275.35
Rate for Payer: Hawaii Medical Service Association Medicare	$250.32
Rate for Payer: Hawaii Western Management Group Commercial	$475.61
Rate for Payer: Health Management Network Commercial	$425.54
Rate for Payer: Humana Medicare	$250.32
Rate for Payer: Kaiser Permanente Commercial	$450.58
Rate for Payer: Kaiser Permanente Medicaid	$255.33
Rate for Payer: Kaiser Permanente Medicare	$250.32
Rate for Payer: MDX Hawaii PPO	$485.62
Rate for Payer: Ohana Health Plan Medicaid	$250.32
Rate for Payer: Ohana Health Plan Medicare	$250.32
Rate for Payer: UnitedHealthcare Medicaid	$300.38
Rate for Payer: UnitedHealthcare Medicare	$250.32
Rate for Payer: University Health Alliance Commercial	$364.92

permethrin 5% cream topical [HHSC]

Facility

$490.29

Service Code	NDC 45802026937
Hospital Charge Code	2500643
Hospital Revenue Code	250
Min. Negotiated Rate	$245.15
Max. Negotiated Rate	$475.58
Rate for Payer: AlohaCare Medicaid	$245.15
Rate for Payer: AlohaCare Medicare	$245.15
Rate for Payer: Cash Price	$318.69
Rate for Payer: Devoted Health Medicare	$269.66
Rate for Payer: Hawaii Medical Service Association Medicare	$245.15
Rate for Payer: Hawaii Western Management Group Commercial	$465.78
Rate for Payer: Health Management Network Commercial	$416.75
Rate for Payer: Humana Medicare	$245.15
Rate for Payer: Kaiser Permanente Commercial	$441.26
Rate for Payer: Kaiser Permanente Medicaid	$250.05
Rate for Payer: Kaiser Permanente Medicare	$245.15
Rate for Payer: MDX Hawaii PPO	$475.58
Rate for Payer: Ohana Health Plan Medicaid	$245.15
Rate for Payer: Ohana Health Plan Medicare	$245.15
Rate for Payer: UnitedHealthcare Medicaid	$294.17
Rate for Payer: UnitedHealthcare Medicare	$245.15
Rate for Payer: University Health Alliance Commercial	$357.37

permethrin 5% cream topical [HHSC]

Facility

$490.29

Service Code	NDC 45802026937
Hospital Charge Code	2500643
Hospital Revenue Code	250
Min. Negotiated Rate	$416.75
Max. Negotiated Rate	$475.58
Rate for Payer: Cash Price	$318.69
Rate for Payer: Health Management Network Commercial	$416.75
Rate for Payer: Kaiser Permanente Commercial	$441.26
Rate for Payer: MDX Hawaii PPO	$475.58

Pfizer vaccine 2nd dose: 0002A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0002A
Hospital Charge Code	9250669
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$103.50

Pfizer vaccine 2nd dose: 0002A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0002A
Hospital Charge Code	9250669
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Pfizer vaccine 3rd dose: 0003A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0003A
Hospital Charge Code	9740276
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Pfizer vaccine 3rd dose: 0003A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0003A
Hospital Charge Code	9740276
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$103.50

Pfizer vaccine Administration 1st dose: 0001A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0001A
Hospital Charge Code	9250670
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Pfizer vaccine Administration 1st dose: 0001A - 30mcg - Pfizer Vaccine Admin Charge

Facility

$142.00

Service Code	HCPCS 0001A
Hospital Charge Code	9250670
Hospital Revenue Code	771
Min. Negotiated Rate	$71.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$103.50

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 69367016304
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$21.57
Rate for Payer: AlohaCare Medicaid	$11.12
Rate for Payer: AlohaCare Medicare	$11.12
Rate for Payer: Cash Price	$14.46
Rate for Payer: Devoted Health Medicare	$12.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11.12
Rate for Payer: Hawaii Western Management Group Commercial	$21.13
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: Kaiser Permanente Medicaid	$11.34
Rate for Payer: Kaiser Permanente Medicare	$11.12
Rate for Payer: MDX Hawaii PPO	$21.57
Rate for Payer: Ohana Health Plan Medicaid	$11.12
Rate for Payer: Ohana Health Plan Medicare	$11.12
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: UnitedHealthcare Medicare	$11.12
Rate for Payer: University Health Alliance Commercial	$16.21

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 65162068210
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$21.57
Rate for Payer: AlohaCare Medicaid	$11.12
Rate for Payer: AlohaCare Medicare	$11.12
Rate for Payer: Cash Price	$14.46
Rate for Payer: Devoted Health Medicare	$12.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11.12
Rate for Payer: Hawaii Western Management Group Commercial	$21.13
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: Kaiser Permanente Medicaid	$11.34
Rate for Payer: Kaiser Permanente Medicare	$11.12
Rate for Payer: MDX Hawaii PPO	$21.57
Rate for Payer: Ohana Health Plan Medicaid	$11.12
Rate for Payer: Ohana Health Plan Medicare	$11.12
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: UnitedHealthcare Medicare	$11.12
Rate for Payer: University Health Alliance Commercial	$16.21

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 69367016304
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$21.57
Rate for Payer: Cash Price	$14.46
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: MDX Hawaii PPO	$21.57

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 51293081101
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$21.57
Rate for Payer: AlohaCare Medicaid	$11.12
Rate for Payer: AlohaCare Medicare	$11.12
Rate for Payer: Cash Price	$14.46
Rate for Payer: Devoted Health Medicare	$12.23
Rate for Payer: Hawaii Medical Service Association Medicare	$11.12
Rate for Payer: Hawaii Western Management Group Commercial	$21.13
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Humana Medicare	$11.12
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: Kaiser Permanente Medicaid	$11.34
Rate for Payer: Kaiser Permanente Medicare	$11.12
Rate for Payer: MDX Hawaii PPO	$21.57
Rate for Payer: Ohana Health Plan Medicaid	$11.12
Rate for Payer: Ohana Health Plan Medicare	$11.12
Rate for Payer: UnitedHealthcare Medicaid	$13.34
Rate for Payer: UnitedHealthcare Medicare	$11.12
Rate for Payer: University Health Alliance Commercial	$16.21

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 51293081101
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$21.57
Rate for Payer: Cash Price	$14.46
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: MDX Hawaii PPO	$21.57

phenazopyridine 200 mg tablet [HHSC]

Facility

$22.24

Service Code	NDC 65162068210
Hospital Charge Code	2500645
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$21.57
Rate for Payer: Cash Price	$14.46
Rate for Payer: Health Management Network Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$20.02
Rate for Payer: MDX Hawaii PPO	$21.57

Know your out-of-pocket cost for care.

All Charges