Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PP ibuprofen 400 mg tab #3 [HHSC]

Facility

$4.34

Service Code	HCPCS J8499
Hospital Charge Code	2530939
Hospital Revenue Code	250
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$4.21
Rate for Payer: Cash Price	$2.82
Rate for Payer: Health Management Network Commercial	$3.69
Rate for Payer: Kaiser Permanente Commercial	$3.91
Rate for Payer: MDX Hawaii PPO	$4.21

PP ibuprofen 600 mg tab #3 [HHSC]

Facility

$8.60

Service Code	HCPCS J8499
Hospital Charge Code	2530940
Hospital Revenue Code	253
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$8.34
Rate for Payer: AlohaCare Medicaid	$4.30
Rate for Payer: AlohaCare Medicaid	$3.02
Rate for Payer: AlohaCare Medicaid	$4.57
Rate for Payer: AlohaCare Medicaid	$2.54
Rate for Payer: AlohaCare Medicare	$4.57
Rate for Payer: AlohaCare Medicare	$4.30
Rate for Payer: AlohaCare Medicare	$2.54
Rate for Payer: AlohaCare Medicare	$3.02
Rate for Payer: Cash Price	$5.93
Rate for Payer: Cash Price	$5.59
Rate for Payer: Cash Price	$3.92
Rate for Payer: Cash Price	$3.30
Rate for Payer: Devoted Health Medicare	$2.79
Rate for Payer: Devoted Health Medicare	$5.02
Rate for Payer: Devoted Health Medicare	$3.32
Rate for Payer: Devoted Health Medicare	$4.73
Rate for Payer: Hawaii Medical Service Association Medicare	$3.02
Rate for Payer: Hawaii Medical Service Association Medicare	$2.54
Rate for Payer: Hawaii Medical Service Association Medicare	$4.30
Rate for Payer: Hawaii Medical Service Association Medicare	$4.57
Rate for Payer: Hawaii Western Management Group Commercial	$8.17
Rate for Payer: Hawaii Western Management Group Commercial	$4.83
Rate for Payer: Hawaii Western Management Group Commercial	$5.73
Rate for Payer: Hawaii Western Management Group Commercial	$8.67
Rate for Payer: Health Management Network Commercial	$7.31
Rate for Payer: Health Management Network Commercial	$4.32
Rate for Payer: Health Management Network Commercial	$7.76
Rate for Payer: Health Management Network Commercial	$5.13
Rate for Payer: Humana Medicare	$3.02
Rate for Payer: Humana Medicare	$4.57
Rate for Payer: Humana Medicare	$4.30
Rate for Payer: Humana Medicare	$2.54
Rate for Payer: Kaiser Permanente Commercial	$7.74
Rate for Payer: Kaiser Permanente Commercial	$4.57
Rate for Payer: Kaiser Permanente Commercial	$5.43
Rate for Payer: Kaiser Permanente Commercial	$8.22
Rate for Payer: Kaiser Permanente Medicaid	$3.08
Rate for Payer: Kaiser Permanente Medicaid	$4.39
Rate for Payer: Kaiser Permanente Medicaid	$4.66
Rate for Payer: Kaiser Permanente Medicaid	$2.59
Rate for Payer: Kaiser Permanente Medicare	$4.57
Rate for Payer: Kaiser Permanente Medicare	$2.54
Rate for Payer: Kaiser Permanente Medicare	$3.02
Rate for Payer: Kaiser Permanente Medicare	$4.30
Rate for Payer: MDX Hawaii PPO	$8.86
Rate for Payer: MDX Hawaii PPO	$5.85
Rate for Payer: MDX Hawaii PPO	$8.34
Rate for Payer: MDX Hawaii PPO	$4.93
Rate for Payer: Ohana Health Plan Medicaid	$2.54
Rate for Payer: Ohana Health Plan Medicaid	$4.30
Rate for Payer: Ohana Health Plan Medicaid	$3.02
Rate for Payer: Ohana Health Plan Medicaid	$4.57
Rate for Payer: Ohana Health Plan Medicare	$4.57
Rate for Payer: Ohana Health Plan Medicare	$2.54
Rate for Payer: Ohana Health Plan Medicare	$4.30
Rate for Payer: Ohana Health Plan Medicare	$3.02
Rate for Payer: UnitedHealthcare Medicare	$3.02
Rate for Payer: UnitedHealthcare Medicare	$4.30
Rate for Payer: UnitedHealthcare Medicare	$2.54
Rate for Payer: UnitedHealthcare Medicare	$4.57
Rate for Payer: University Health Alliance Commercial	$3.70
Rate for Payer: University Health Alliance Commercial	$6.27
Rate for Payer: University Health Alliance Commercial	$4.40
Rate for Payer: University Health Alliance Commercial	$6.65

PP ibuprofen 600 mg tab #3 [HHSC]

Facility

$6.03

Service Code	HCPCS J8499
Hospital Charge Code	2530940
Hospital Revenue Code	250
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$5.85
Rate for Payer: Cash Price	$3.92
Rate for Payer: Cash Price	$5.93
Rate for Payer: Cash Price	$5.59
Rate for Payer: Cash Price	$3.30
Rate for Payer: Health Management Network Commercial	$5.13
Rate for Payer: Health Management Network Commercial	$7.76
Rate for Payer: Health Management Network Commercial	$4.32
Rate for Payer: Health Management Network Commercial	$7.31
Rate for Payer: Kaiser Permanente Commercial	$8.22
Rate for Payer: Kaiser Permanente Commercial	$4.57
Rate for Payer: Kaiser Permanente Commercial	$5.43
Rate for Payer: Kaiser Permanente Commercial	$7.74
Rate for Payer: MDX Hawaii PPO	$8.86
Rate for Payer: MDX Hawaii PPO	$4.93
Rate for Payer: MDX Hawaii PPO	$5.85
Rate for Payer: MDX Hawaii PPO	$8.34

PP indomethacin 25 mg cap #3 [HHSC]

Facility

$6.70

Service Code	HCPCS J8499
Hospital Charge Code	2530942
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$6.50
Rate for Payer: Cash Price	$4.36
Rate for Payer: Health Management Network Commercial	$5.70
Rate for Payer: Kaiser Permanente Commercial	$6.03
Rate for Payer: MDX Hawaii PPO	$6.50

PP indomethacin 25 mg cap #3 [HHSC]

Facility

$6.70

Service Code	HCPCS J8499
Hospital Charge Code	2530942
Hospital Revenue Code	253
Min. Negotiated Rate	$3.35
Max. Negotiated Rate	$6.50
Rate for Payer: AlohaCare Medicaid	$3.35
Rate for Payer: AlohaCare Medicare	$3.35
Rate for Payer: Cash Price	$4.36
Rate for Payer: Devoted Health Medicare	$3.69
Rate for Payer: Hawaii Medical Service Association Medicare	$3.35
Rate for Payer: Hawaii Western Management Group Commercial	$6.37
Rate for Payer: Health Management Network Commercial	$5.70
Rate for Payer: Humana Medicare	$3.35
Rate for Payer: Kaiser Permanente Commercial	$6.03
Rate for Payer: Kaiser Permanente Medicaid	$3.42
Rate for Payer: Kaiser Permanente Medicare	$3.35
Rate for Payer: MDX Hawaii PPO	$6.50
Rate for Payer: Ohana Health Plan Medicaid	$3.35
Rate for Payer: Ohana Health Plan Medicare	$3.35
Rate for Payer: UnitedHealthcare Medicare	$3.35
Rate for Payer: University Health Alliance Commercial	$4.88

PP loperamide 2 mg cap #3 [HHSC]

Facility

$14.64

Service Code	HCPCS A9150
Hospital Charge Code	2530943
Hospital Revenue Code	253
Min. Negotiated Rate	$7.32
Max. Negotiated Rate	$14.20
Rate for Payer: AlohaCare Medicaid	$7.32
Rate for Payer: AlohaCare Medicare	$7.32
Rate for Payer: Cash Price	$9.52
Rate for Payer: Devoted Health Medicare	$8.05
Rate for Payer: Hawaii Medical Service Association Medicare	$7.32
Rate for Payer: Hawaii Western Management Group Commercial	$13.91
Rate for Payer: Health Management Network Commercial	$12.44
Rate for Payer: Humana Medicare	$7.32
Rate for Payer: Kaiser Permanente Commercial	$13.18
Rate for Payer: Kaiser Permanente Medicaid	$7.47
Rate for Payer: Kaiser Permanente Medicare	$7.32
Rate for Payer: MDX Hawaii PPO	$14.20
Rate for Payer: Ohana Health Plan Medicaid	$7.32
Rate for Payer: Ohana Health Plan Medicare	$7.32
Rate for Payer: UnitedHealthcare Medicare	$7.32
Rate for Payer: University Health Alliance Commercial	$10.67

PP loperamide 2 mg cap #3 [HHSC]

Facility

$14.64

Service Code	HCPCS A9150
Hospital Charge Code	2530943
Hospital Revenue Code	250
Min. Negotiated Rate	$12.44
Max. Negotiated Rate	$14.20
Rate for Payer: Cash Price	$9.52
Rate for Payer: Health Management Network Commercial	$12.44
Rate for Payer: Kaiser Permanente Commercial	$13.18
Rate for Payer: MDX Hawaii PPO	$14.20

PP LORazepam 1 mg tab #4 [HHSC]

Facility

$19.57

Service Code	HCPCS J8499
Hospital Charge Code	2530944
Hospital Revenue Code	253
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$18.98
Rate for Payer: AlohaCare Medicaid	$9.79
Rate for Payer: AlohaCare Medicare	$9.79
Rate for Payer: Cash Price	$12.72
Rate for Payer: Devoted Health Medicare	$10.76
Rate for Payer: Hawaii Medical Service Association Medicare	$9.79
Rate for Payer: Hawaii Western Management Group Commercial	$18.59
Rate for Payer: Health Management Network Commercial	$16.63
Rate for Payer: Humana Medicare	$9.79
Rate for Payer: Kaiser Permanente Commercial	$17.61
Rate for Payer: Kaiser Permanente Medicaid	$9.98
Rate for Payer: Kaiser Permanente Medicare	$9.79
Rate for Payer: MDX Hawaii PPO	$18.98
Rate for Payer: Ohana Health Plan Medicaid	$9.79
Rate for Payer: Ohana Health Plan Medicare	$9.79
Rate for Payer: UnitedHealthcare Medicare	$9.79
Rate for Payer: University Health Alliance Commercial	$14.26

PP LORazepam 1 mg tab #4 [HHSC]

Facility

$19.57

Service Code	HCPCS J8499
Hospital Charge Code	2530944
Hospital Revenue Code	250
Min. Negotiated Rate	$16.63
Max. Negotiated Rate	$18.98
Rate for Payer: Cash Price	$12.72
Rate for Payer: Health Management Network Commercial	$16.63
Rate for Payer: Kaiser Permanente Commercial	$17.61
Rate for Payer: MDX Hawaii PPO	$18.98

PP magic mouthwash 4 oz [HHSC]

Facility

$467.72

Service Code	HCPCS J8499
Hospital Charge Code	2530946
Hospital Revenue Code	250
Min. Negotiated Rate	$397.56
Max. Negotiated Rate	$453.69
Rate for Payer: Cash Price	$304.02
Rate for Payer: Health Management Network Commercial	$397.56
Rate for Payer: Kaiser Permanente Commercial	$420.95
Rate for Payer: MDX Hawaii PPO	$453.69

PP magic mouthwash 4 oz [HHSC]

Facility

$467.72

Service Code	HCPCS J8499
Hospital Charge Code	2530946
Hospital Revenue Code	253
Min. Negotiated Rate	$233.86
Max. Negotiated Rate	$453.69
Rate for Payer: AlohaCare Medicaid	$233.86
Rate for Payer: AlohaCare Medicare	$233.86
Rate for Payer: Cash Price	$304.02
Rate for Payer: Devoted Health Medicare	$257.25
Rate for Payer: Hawaii Medical Service Association Medicare	$233.86
Rate for Payer: Hawaii Western Management Group Commercial	$444.33
Rate for Payer: Health Management Network Commercial	$397.56
Rate for Payer: Humana Medicare	$233.86
Rate for Payer: Kaiser Permanente Commercial	$420.95
Rate for Payer: Kaiser Permanente Medicaid	$238.54
Rate for Payer: Kaiser Permanente Medicare	$233.86
Rate for Payer: MDX Hawaii PPO	$453.69
Rate for Payer: Ohana Health Plan Medicaid	$233.86
Rate for Payer: Ohana Health Plan Medicare	$233.86
Rate for Payer: UnitedHealthcare Medicare	$233.86
Rate for Payer: University Health Alliance Commercial	$340.92

PP meclizine 25 mg tab #3 [HHSC]

Facility

$14.28

Service Code	HCPCS J8499
Hospital Charge Code	2530947
Hospital Revenue Code	250
Min. Negotiated Rate	$12.14
Max. Negotiated Rate	$13.85
Rate for Payer: Cash Price	$9.28
Rate for Payer: Health Management Network Commercial	$12.14
Rate for Payer: Kaiser Permanente Commercial	$12.85
Rate for Payer: MDX Hawaii PPO	$13.85

PP meclizine 25 mg tab #3 [HHSC]

Facility

$14.28

Service Code	HCPCS J8499
Hospital Charge Code	2530947
Hospital Revenue Code	253
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$13.85
Rate for Payer: AlohaCare Medicaid	$7.14
Rate for Payer: AlohaCare Medicare	$7.14
Rate for Payer: Cash Price	$9.28
Rate for Payer: Devoted Health Medicare	$7.85
Rate for Payer: Hawaii Medical Service Association Medicare	$7.14
Rate for Payer: Hawaii Western Management Group Commercial	$13.57
Rate for Payer: Health Management Network Commercial	$12.14
Rate for Payer: Humana Medicare	$7.14
Rate for Payer: Kaiser Permanente Commercial	$12.85
Rate for Payer: Kaiser Permanente Medicaid	$7.28
Rate for Payer: Kaiser Permanente Medicare	$7.14
Rate for Payer: MDX Hawaii PPO	$13.85
Rate for Payer: Ohana Health Plan Medicaid	$7.14
Rate for Payer: Ohana Health Plan Medicare	$7.14
Rate for Payer: UnitedHealthcare Medicare	$7.14
Rate for Payer: University Health Alliance Commercial	$10.41

PP mupirocin 2% oint 22gm [HHSC]

Facility

$196.84

Service Code	HCPCS A9270
Hospital Charge Code	2530926
Hospital Revenue Code	253
Min. Negotiated Rate	$98.42
Max. Negotiated Rate	$190.93
Rate for Payer: AlohaCare Medicaid	$98.42
Rate for Payer: AlohaCare Medicaid	$32.59
Rate for Payer: AlohaCare Medicare	$98.42
Rate for Payer: AlohaCare Medicare	$32.59
Rate for Payer: Cash Price	$42.37
Rate for Payer: Cash Price	$127.95
Rate for Payer: Devoted Health Medicare	$108.26
Rate for Payer: Devoted Health Medicare	$35.85
Rate for Payer: Hawaii Medical Service Association Medicare	$32.59
Rate for Payer: Hawaii Medical Service Association Medicare	$98.42
Rate for Payer: Hawaii Western Management Group Commercial	$61.92
Rate for Payer: Hawaii Western Management Group Commercial	$187.00
Rate for Payer: Health Management Network Commercial	$167.31
Rate for Payer: Health Management Network Commercial	$55.40
Rate for Payer: Humana Medicare	$32.59
Rate for Payer: Humana Medicare	$98.42
Rate for Payer: Kaiser Permanente Commercial	$177.16
Rate for Payer: Kaiser Permanente Commercial	$58.66
Rate for Payer: Kaiser Permanente Medicaid	$33.24
Rate for Payer: Kaiser Permanente Medicaid	$100.39
Rate for Payer: Kaiser Permanente Medicare	$32.59
Rate for Payer: Kaiser Permanente Medicare	$98.42
Rate for Payer: MDX Hawaii PPO	$63.22
Rate for Payer: MDX Hawaii PPO	$190.93
Rate for Payer: Ohana Health Plan Medicaid	$98.42
Rate for Payer: Ohana Health Plan Medicaid	$32.59
Rate for Payer: Ohana Health Plan Medicare	$98.42
Rate for Payer: Ohana Health Plan Medicare	$32.59
Rate for Payer: UnitedHealthcare Medicare	$98.42
Rate for Payer: UnitedHealthcare Medicare	$32.59
Rate for Payer: University Health Alliance Commercial	$47.51
Rate for Payer: University Health Alliance Commercial	$143.48

PP mupirocin 2% oint 22gm [HHSC]

Facility

$65.18

Service Code	HCPCS A9270
Hospital Charge Code	2530926
Hospital Revenue Code	250
Min. Negotiated Rate	$55.40
Max. Negotiated Rate	$63.22
Rate for Payer: Cash Price	$42.37
Rate for Payer: Cash Price	$127.95
Rate for Payer: Health Management Network Commercial	$55.40
Rate for Payer: Health Management Network Commercial	$167.31
Rate for Payer: Kaiser Permanente Commercial	$58.66
Rate for Payer: Kaiser Permanente Commercial	$177.16
Rate for Payer: MDX Hawaii PPO	$190.93
Rate for Payer: MDX Hawaii PPO	$63.22

PP naloxone 4 mg/0.1 mL nasal spray #2 [HHSC]

Facility

$288.32

Service Code	HCPCS A9150
Hospital Charge Code	2531160
Hospital Revenue Code	250
Min. Negotiated Rate	$245.07
Max. Negotiated Rate	$279.67
Rate for Payer: Cash Price	$187.41
Rate for Payer: Health Management Network Commercial	$245.07
Rate for Payer: Kaiser Permanente Commercial	$259.49
Rate for Payer: MDX Hawaii PPO	$279.67

PP naloxone 4 mg/0.1 mL nasal spray #2 [HHSC]

Facility

$288.32

Service Code	HCPCS A9150
Hospital Charge Code	2531160
Hospital Revenue Code	253
Min. Negotiated Rate	$144.16
Max. Negotiated Rate	$279.67
Rate for Payer: AlohaCare Medicaid	$144.16
Rate for Payer: AlohaCare Medicare	$144.16
Rate for Payer: Cash Price	$187.41
Rate for Payer: Devoted Health Medicare	$158.58
Rate for Payer: Hawaii Medical Service Association Medicare	$144.16
Rate for Payer: Hawaii Western Management Group Commercial	$273.90
Rate for Payer: Health Management Network Commercial	$245.07
Rate for Payer: Humana Medicare	$144.16
Rate for Payer: Kaiser Permanente Commercial	$259.49
Rate for Payer: Kaiser Permanente Medicaid	$147.04
Rate for Payer: Kaiser Permanente Medicare	$144.16
Rate for Payer: MDX Hawaii PPO	$279.67
Rate for Payer: Ohana Health Plan Medicaid	$144.16
Rate for Payer: Ohana Health Plan Medicare	$144.16
Rate for Payer: UnitedHealthcare Medicare	$144.16
Rate for Payer: University Health Alliance Commercial	$210.16

PP naphaz-pheniram oph 15mL [HHSC]

Facility

$5.82

Service Code	HCPCS A9150
Hospital Charge Code	2530969
Hospital Revenue Code	253
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$5.65
Rate for Payer: AlohaCare Medicaid	$2.91
Rate for Payer: AlohaCare Medicaid	$4.51
Rate for Payer: AlohaCare Medicare	$2.91
Rate for Payer: AlohaCare Medicare	$4.51
Rate for Payer: Cash Price	$5.86
Rate for Payer: Cash Price	$3.78
Rate for Payer: Devoted Health Medicare	$3.20
Rate for Payer: Devoted Health Medicare	$4.96
Rate for Payer: Hawaii Medical Service Association Medicare	$4.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2.91
Rate for Payer: Hawaii Western Management Group Commercial	$8.57
Rate for Payer: Hawaii Western Management Group Commercial	$5.53
Rate for Payer: Health Management Network Commercial	$4.95
Rate for Payer: Health Management Network Commercial	$7.67
Rate for Payer: Humana Medicare	$4.51
Rate for Payer: Humana Medicare	$2.91
Rate for Payer: Kaiser Permanente Commercial	$5.24
Rate for Payer: Kaiser Permanente Commercial	$8.12
Rate for Payer: Kaiser Permanente Medicaid	$4.60
Rate for Payer: Kaiser Permanente Medicaid	$2.97
Rate for Payer: Kaiser Permanente Medicare	$4.51
Rate for Payer: Kaiser Permanente Medicare	$2.91
Rate for Payer: MDX Hawaii PPO	$8.75
Rate for Payer: MDX Hawaii PPO	$5.65
Rate for Payer: Ohana Health Plan Medicaid	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$4.51
Rate for Payer: Ohana Health Plan Medicare	$2.91
Rate for Payer: Ohana Health Plan Medicare	$4.51
Rate for Payer: UnitedHealthcare Medicare	$2.91
Rate for Payer: UnitedHealthcare Medicare	$4.51
Rate for Payer: University Health Alliance Commercial	$6.57
Rate for Payer: University Health Alliance Commercial	$4.24

PP naphaz-pheniram oph 15mL [HHSC]

Facility

$9.02

Service Code	HCPCS A9150
Hospital Charge Code	2530969
Hospital Revenue Code	250
Min. Negotiated Rate	$7.67
Max. Negotiated Rate	$8.75
Rate for Payer: Cash Price	$5.86
Rate for Payer: Cash Price	$3.78
Rate for Payer: Health Management Network Commercial	$7.67
Rate for Payer: Health Management Network Commercial	$4.95
Rate for Payer: Kaiser Permanente Commercial	$8.12
Rate for Payer: Kaiser Permanente Commercial	$5.24
Rate for Payer: MDX Hawaii PPO	$5.65
Rate for Payer: MDX Hawaii PPO	$8.75

PP neomy/poly/HC otic 10 mL [HHSC]

Facility

$450.80

Service Code	HCPCS A9270
Hospital Charge Code	2530948
Hospital Revenue Code	250
Min. Negotiated Rate	$383.18
Max. Negotiated Rate	$437.28
Rate for Payer: Cash Price	$293.02
Rate for Payer: Cash Price	$299.78
Rate for Payer: Health Management Network Commercial	$383.18
Rate for Payer: Health Management Network Commercial	$392.02
Rate for Payer: Kaiser Permanente Commercial	$405.72
Rate for Payer: Kaiser Permanente Commercial	$415.08
Rate for Payer: MDX Hawaii PPO	$447.36
Rate for Payer: MDX Hawaii PPO	$437.28

PP neomy/poly/HC otic 10 mL [HHSC]

Facility

$461.20

Service Code	HCPCS A9270
Hospital Charge Code	2530948
Hospital Revenue Code	253
Min. Negotiated Rate	$230.60
Max. Negotiated Rate	$447.36
Rate for Payer: AlohaCare Medicaid	$230.60
Rate for Payer: AlohaCare Medicaid	$225.40
Rate for Payer: AlohaCare Medicare	$225.40
Rate for Payer: AlohaCare Medicare	$230.60
Rate for Payer: Cash Price	$293.02
Rate for Payer: Cash Price	$299.78
Rate for Payer: Devoted Health Medicare	$253.66
Rate for Payer: Devoted Health Medicare	$247.94
Rate for Payer: Hawaii Medical Service Association Medicare	$225.40
Rate for Payer: Hawaii Medical Service Association Medicare	$230.60
Rate for Payer: Hawaii Western Management Group Commercial	$428.26
Rate for Payer: Hawaii Western Management Group Commercial	$438.14
Rate for Payer: Health Management Network Commercial	$392.02
Rate for Payer: Health Management Network Commercial	$383.18
Rate for Payer: Humana Medicare	$230.60
Rate for Payer: Humana Medicare	$225.40
Rate for Payer: Kaiser Permanente Commercial	$405.72
Rate for Payer: Kaiser Permanente Commercial	$415.08
Rate for Payer: Kaiser Permanente Medicaid	$235.21
Rate for Payer: Kaiser Permanente Medicaid	$229.91
Rate for Payer: Kaiser Permanente Medicare	$225.40
Rate for Payer: Kaiser Permanente Medicare	$230.60
Rate for Payer: MDX Hawaii PPO	$437.28
Rate for Payer: MDX Hawaii PPO	$447.36
Rate for Payer: Ohana Health Plan Medicaid	$225.40
Rate for Payer: Ohana Health Plan Medicaid	$230.60
Rate for Payer: Ohana Health Plan Medicare	$225.40
Rate for Payer: Ohana Health Plan Medicare	$230.60
Rate for Payer: UnitedHealthcare Medicare	$230.60
Rate for Payer: UnitedHealthcare Medicare	$225.40
Rate for Payer: University Health Alliance Commercial	$336.17
Rate for Payer: University Health Alliance Commercial	$328.59

PP neomy/polym/gram OPHT drops 10mL [HHSC]

Facility

$313.61

Service Code	HCPCS A9270
Hospital Charge Code	2531011
Hospital Revenue Code	250
Min. Negotiated Rate	$266.57
Max. Negotiated Rate	$304.20
Rate for Payer: Cash Price	$203.85
Rate for Payer: Health Management Network Commercial	$266.57
Rate for Payer: Kaiser Permanente Commercial	$282.25
Rate for Payer: MDX Hawaii PPO	$304.20

PP neomy/polym/gram OPHT drops 10mL [HHSC]

Facility

$313.61

Service Code	HCPCS A9270
Hospital Charge Code	2531011
Hospital Revenue Code	253
Min. Negotiated Rate	$156.81
Max. Negotiated Rate	$304.20
Rate for Payer: AlohaCare Medicaid	$156.81
Rate for Payer: AlohaCare Medicare	$156.81
Rate for Payer: Cash Price	$203.85
Rate for Payer: Devoted Health Medicare	$172.49
Rate for Payer: Hawaii Medical Service Association Medicare	$156.81
Rate for Payer: Hawaii Western Management Group Commercial	$297.93
Rate for Payer: Health Management Network Commercial	$266.57
Rate for Payer: Humana Medicare	$156.81
Rate for Payer: Kaiser Permanente Commercial	$282.25
Rate for Payer: Kaiser Permanente Medicaid	$159.94
Rate for Payer: Kaiser Permanente Medicare	$156.81
Rate for Payer: MDX Hawaii PPO	$304.20
Rate for Payer: Ohana Health Plan Medicaid	$156.81
Rate for Payer: Ohana Health Plan Medicare	$156.81
Rate for Payer: UnitedHealthcare Medicare	$156.81
Rate for Payer: University Health Alliance Commercial	$228.59

PP nitroglycerin 0.4mg SL tab #25 [HHSC]

Facility

$3.00

Service Code	HCPCS J8499
Hospital Charge Code	2530994
Hospital Revenue Code	253
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 Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

PP nitroglycerin 0.4mg SL tab #25 [HHSC]

Facility

$3.00

Service Code	HCPCS J8499
Hospital Charge Code	2530994
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

Know your out-of-pocket cost for care.

All Charges