Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

phenytoin ER 100 mg capsule [HHSC]

Facility

$3.56

Service Code	NDC 65162021210
Hospital Charge Code	2500656
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$3.45
Rate for Payer: Cash Price	$2.31
Rate for Payer: Health Management Network Commercial	$3.03
Rate for Payer: Kaiser Permanente Commercial	$3.20
Rate for Payer: MDX Hawaii PPO	$3.45

phenytoin ER 100 mg capsule [HHSC]

Facility

$3.56

Service Code	NDC 51672411101
Hospital Charge Code	2500656
Hospital Revenue Code	250
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$3.45
Rate for Payer: Cash Price	$2.31
Rate for Payer: Health Management Network Commercial	$3.03
Rate for Payer: Kaiser Permanente Commercial	$3.20
Rate for Payer: MDX Hawaii PPO	$3.45

Phenytoin FSI

Facility

$151.00

Service Code	HCPCS 80185
Hospital Charge Code	8118012
Hospital Revenue Code	301
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

Phenytoin FSI

Facility

$151.00

Service Code	HCPCS 80185
Hospital Charge Code	8118012
Hospital Revenue Code	301
Min. Negotiated Rate	$13.25
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$18.32
Rate for Payer: Hawaii Medical Service Association Commercial	$16.56
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.24
Rate for Payer: Hawaii Western Management Group Commercial	$13.25
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$18.32
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$34.26

PH, Fluid FSI

Facility

$45.00

Service Code	HCPCS 83986
Hospital Charge Code	8404527
Hospital Revenue Code	301
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

PH, Fluid FSI

Facility

$45.00

Service Code	HCPCS 83986
Hospital Charge Code	8404527
Hospital Revenue Code	301
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$22.50
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$24.75
Rate for Payer: Hawaii Medical Service Association ABD	$4.95
Rate for Payer: Hawaii Medical Service Association Commercial	$4.47
Rate for Payer: Hawaii Medical Service Association Medicare	$22.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.20
Rate for Payer: Hawaii Western Management Group Commercial	$3.58
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$22.50
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$22.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$22.50
Rate for Payer: Ohana Health Plan Medicare	$22.50
Rate for Payer: UnitedHealthcare Medicaid	$4.95
Rate for Payer: UnitedHealthcare Medicare	$22.50
Rate for Payer: University Health Alliance Commercial	$9.25

Phlebotomy

Facility

$562.00

Service Code	HCPCS 99195
Hospital Charge Code	8527783
Hospital Revenue Code	940
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$545.14
Rate for Payer: AlohaCare Medicaid	$281.00
Rate for Payer: AlohaCare Medicare	$281.00
Rate for Payer: Cash Price	$365.30
Rate for Payer: Cash Price	$365.30
Rate for Payer: Devoted Health Medicare	$309.10
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$281.00
Rate for Payer: Hawaii Western Management Group Commercial	$533.90
Rate for Payer: Health Management Network Commercial	$477.70
Rate for Payer: Humana Medicare	$281.00
Rate for Payer: Kaiser Permanente Commercial	$505.80
Rate for Payer: Kaiser Permanente Medicaid	$286.62
Rate for Payer: Kaiser Permanente Medicare	$281.00
Rate for Payer: MDX Hawaii PPO	$545.14
Rate for Payer: Ohana Health Plan Medicaid	$281.00
Rate for Payer: Ohana Health Plan Medicare	$281.00
Rate for Payer: UnitedHealthcare Medicaid	$14.85
Rate for Payer: UnitedHealthcare Medicare	$281.00
Rate for Payer: University Health Alliance Commercial	$409.64

Phlebotomy

Facility

$562.00

Service Code	HCPCS 99195
Hospital Charge Code	8527783
Hospital Revenue Code	940
Min. Negotiated Rate	$477.70
Max. Negotiated Rate	$545.14
Rate for Payer: Cash Price	$365.30
Rate for Payer: Health Management Network Commercial	$477.70
Rate for Payer: Kaiser Permanente Commercial	$505.80
Rate for Payer: MDX Hawaii PPO	$545.14

Phonophoresis Charge

Facility

$104.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	8111736
Hospital Revenue Code	420
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

Phonophoresis Charge

Facility

$104.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	8111736
Hospital Revenue Code	420
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$75.81

Phosphorus FSI

Facility

$67.00

Service Code	HCPCS 84100
Hospital Charge Code	8118014
Hospital Revenue Code	301
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Phosphorus FSI

Facility

$67.00

Service Code	HCPCS 84100
Hospital Charge Code	8118014
Hospital Revenue Code	301
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$6.56
Rate for Payer: Hawaii Medical Service Association Commercial	$5.92
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.89
Rate for Payer: Hawaii Western Management Group Commercial	$4.74
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$12.27

Phosphorus Urine Timed FSI

Facility

$57.00

Service Code	HCPCS 84105
Hospital Charge Code	8228908
Hospital Revenue Code	301
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$37.05
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: MDX Hawaii PPO	$55.29

Phosphorus Urine Timed FSI

Facility

$57.00

Service Code	HCPCS 84105
Hospital Charge Code	8228908
Hospital Revenue Code	301
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$55.29
Rate for Payer: AlohaCare Medicaid	$28.50
Rate for Payer: AlohaCare Medicare	$28.50
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cash Price	$37.05
Rate for Payer: Devoted Health Medicare	$31.35
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$28.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Humana Medicare	$28.50
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: Kaiser Permanente Medicare	$28.50
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: Ohana Health Plan Medicaid	$28.50
Rate for Payer: Ohana Health Plan Medicare	$28.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$28.50
Rate for Payer: University Health Alliance Commercial	$13.38

Phototherapy

Facility

$132.00

Hospital Charge Code	607696
Hospital Revenue Code	940
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

Phototherapy

Facility

$132.00

Hospital Charge Code	607696
Hospital Revenue Code	940
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$96.21

physostigmine 2 mg/2 ml ampule [HHSC]

Facility

$427.34

Service Code	NDC 17478051002
Hospital Charge Code	2500659
Hospital Revenue Code	250
Min. Negotiated Rate	$363.24
Max. Negotiated Rate	$414.52
Rate for Payer: Cash Price	$277.77
Rate for Payer: Health Management Network Commercial	$363.24
Rate for Payer: Kaiser Permanente Commercial	$384.61
Rate for Payer: MDX Hawaii PPO	$414.52

physostigmine 2 mg/2 ml ampule [HHSC]

Facility

$427.34

Service Code	NDC 17478051002
Hospital Charge Code	2500659
Hospital Revenue Code	250
Min. Negotiated Rate	$213.67
Max. Negotiated Rate	$414.52
Rate for Payer: AlohaCare Medicaid	$213.67
Rate for Payer: AlohaCare Medicare	$213.67
Rate for Payer: Cash Price	$277.77
Rate for Payer: Devoted Health Medicare	$235.04
Rate for Payer: Hawaii Medical Service Association Medicare	$213.67
Rate for Payer: Hawaii Western Management Group Commercial	$405.97
Rate for Payer: Health Management Network Commercial	$363.24
Rate for Payer: Humana Medicare	$213.67
Rate for Payer: Kaiser Permanente Commercial	$384.61
Rate for Payer: Kaiser Permanente Medicaid	$217.94
Rate for Payer: Kaiser Permanente Medicare	$213.67
Rate for Payer: MDX Hawaii PPO	$414.52
Rate for Payer: Ohana Health Plan Medicaid	$213.67
Rate for Payer: Ohana Health Plan Medicare	$213.67
Rate for Payer: UnitedHealthcare Medicaid	$256.40
Rate for Payer: UnitedHealthcare Medicare	$213.67
Rate for Payer: University Health Alliance Commercial	$311.49

phytonadione 10 mg/ml ampule [HHSC]

Facility

$230.09

Service Code	HCPCS J3430
Hospital Charge Code	2500661
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$223.19
Rate for Payer: AlohaCare Medicaid	$115.05
Rate for Payer: AlohaCare Medicare	$115.05
Rate for Payer: Cash Price	$149.56
Rate for Payer: Cash Price	$149.56
Rate for Payer: Devoted Health Medicare	$126.55
Rate for Payer: Hawaii Medical Service Association ABD	$2.84
Rate for Payer: Hawaii Medical Service Association Medicare	$115.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.84
Rate for Payer: Hawaii Western Management Group Commercial	$218.59
Rate for Payer: Health Management Network Commercial	$195.58
Rate for Payer: Humana Medicare	$115.05
Rate for Payer: Kaiser Permanente Commercial	$207.08
Rate for Payer: Kaiser Permanente Medicaid	$117.35
Rate for Payer: Kaiser Permanente Medicare	$115.05
Rate for Payer: MDX Hawaii PPO	$223.19
Rate for Payer: Ohana Health Plan Medicaid	$115.05
Rate for Payer: Ohana Health Plan Medicare	$115.05
Rate for Payer: UnitedHealthcare Medicaid	$138.05
Rate for Payer: UnitedHealthcare Medicare	$115.05
Rate for Payer: University Health Alliance Commercial	$167.71

phytonadione 10 mg/ml ampule [HHSC]

Facility

$230.09

Service Code	HCPCS J3430
Hospital Charge Code	2500661
Hospital Revenue Code	250
Min. Negotiated Rate	$195.58
Max. Negotiated Rate	$223.19
Rate for Payer: Cash Price	$149.56
Rate for Payer: Health Management Network Commercial	$195.58
Rate for Payer: Kaiser Permanente Commercial	$207.08
Rate for Payer: MDX Hawaii PPO	$223.19

phytonadione 1 mg/0.5 mL syringe [HHSC]

Facility

$131.01

Service Code	HCPCS J3430
Hospital Charge Code	2501130
Hospital Revenue Code	250
Min. Negotiated Rate	$111.36
Max. Negotiated Rate	$127.08
Rate for Payer: Cash Price	$85.16
Rate for Payer: Health Management Network Commercial	$111.36
Rate for Payer: Kaiser Permanente Commercial	$117.91
Rate for Payer: MDX Hawaii PPO	$127.08

phytonadione 1 mg/0.5 mL syringe [HHSC]

Facility

$131.01

Service Code	HCPCS J3430
Hospital Charge Code	2501130
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$127.08
Rate for Payer: AlohaCare Medicaid	$65.50
Rate for Payer: AlohaCare Medicare	$65.50
Rate for Payer: Cash Price	$85.16
Rate for Payer: Cash Price	$85.16
Rate for Payer: Devoted Health Medicare	$72.06
Rate for Payer: Hawaii Medical Service Association ABD	$2.84
Rate for Payer: Hawaii Medical Service Association Medicare	$65.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.84
Rate for Payer: Hawaii Western Management Group Commercial	$124.46
Rate for Payer: Health Management Network Commercial	$111.36
Rate for Payer: Humana Medicare	$65.50
Rate for Payer: Kaiser Permanente Commercial	$117.91
Rate for Payer: Kaiser Permanente Medicaid	$66.82
Rate for Payer: Kaiser Permanente Medicare	$65.50
Rate for Payer: MDX Hawaii PPO	$127.08
Rate for Payer: Ohana Health Plan Medicaid	$65.50
Rate for Payer: Ohana Health Plan Medicare	$65.50
Rate for Payer: UnitedHealthcare Medicaid	$78.61
Rate for Payer: UnitedHealthcare Medicare	$65.50
Rate for Payer: University Health Alliance Commercial	$95.49

PICC line insertion w USN guidance, < 5 y.o.

Facility

$3,463.00

Service Code	HCPCS 36572
Hospital Charge Code	8515466
Hospital Revenue Code	361
Min. Negotiated Rate	$2,943.55
Max. Negotiated Rate	$3,359.11
Rate for Payer: Cash Price	$2,250.95
Rate for Payer: Health Management Network Commercial	$2,943.55
Rate for Payer: Kaiser Permanente Commercial	$3,116.70
Rate for Payer: MDX Hawaii PPO	$3,359.11

PICC line insertion w USN guidance, < 5 y.o.

Facility

$3,463.00

Service Code	HCPCS 36572
Hospital Charge Code	8515466
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,359.11
Rate for Payer: AlohaCare Medicaid	$1,731.50
Rate for Payer: AlohaCare Medicare	$1,731.50
Rate for Payer: Cash Price	$2,250.95
Rate for Payer: Cash Price	$2,250.95
Rate for Payer: Cash Price	$2,250.95
Rate for Payer: Devoted Health Medicare	$1,904.65
Rate for Payer: Hawaii Medical Service Association Commercial	$801.11
Rate for Payer: Hawaii Medical Service Association Medicare	$1,731.50
Rate for Payer: Health Management Network Commercial	$2,943.55
Rate for Payer: Humana Medicare	$1,731.50
Rate for Payer: Kaiser Permanente Commercial	$3,116.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,731.50
Rate for Payer: MDX Hawaii PPO	$3,359.11
Rate for Payer: Ohana Health Plan Medicaid	$1,731.50
Rate for Payer: Ohana Health Plan Medicare	$1,731.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,731.50
Rate for Payer: University Health Alliance Commercial	$2,524.18

PICC line insertion, w USN Guidance, >= 5 y.o.

Facility

$3,667.00

Service Code	HCPCS 36573
Hospital Charge Code	8515467
Hospital Revenue Code	361
Min. Negotiated Rate	$3,116.95
Max. Negotiated Rate	$3,556.99
Rate for Payer: Cash Price	$2,383.55
Rate for Payer: Health Management Network Commercial	$3,116.95
Rate for Payer: Kaiser Permanente Commercial	$3,300.30
Rate for Payer: MDX Hawaii PPO	$3,556.99

Know your out-of-pocket cost for care.

All Charges