Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

SEPTIC ARTHRITIS WITH CC

Facility

$26,311.87

Service Code	MSDRG 549
Min. Negotiated Rate	$26,311.87
Max. Negotiated Rate	$26,311.87
Rate for Payer: Hawaii Medical Service Association Commercial	$26,311.87

SEPTIC ARTHRITIS WITH MCC

Facility

$26,311.87

Service Code	MSDRG 548
Min. Negotiated Rate	$26,311.87
Max. Negotiated Rate	$26,311.87
Rate for Payer: Hawaii Medical Service Association Commercial	$26,311.87

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$26,311.87

Service Code	MSDRG 550
Min. Negotiated Rate	$26,311.87
Max. Negotiated Rate	$26,311.87
Rate for Payer: Hawaii Medical Service Association Commercial	$26,311.87

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$196,523.17

Service Code	MSDRG 870
Min. Negotiated Rate	$196,523.17
Max. Negotiated Rate	$196,523.17
Rate for Payer: Hawaii Medical Service Association Commercial	$196,523.17

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$43,904.11

Service Code	MSDRG 871
Min. Negotiated Rate	$43,904.11
Max. Negotiated Rate	$43,904.11
Rate for Payer: Hawaii Medical Service Association Commercial	$43,904.11

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$43,878.62

Service Code	MSDRG 872
Min. Negotiated Rate	$43,878.62
Max. Negotiated Rate	$43,878.62
Rate for Payer: Hawaii Medical Service Association Commercial	$43,878.62

sertraline 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687024201
Hospital Charge Code	2500738
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

sertraline 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687024201
Hospital Charge Code	2500738
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

sertraline 50 mg tablet [HHSC]

Facility

$15.84

Service Code	NDC 65862001201
Hospital Charge Code	2500738
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.36
Rate for Payer: AlohaCare Medicaid	$7.92
Rate for Payer: AlohaCare Medicare	$7.92
Rate for Payer: Cash Price	$10.30
Rate for Payer: Devoted Health Medicare	$8.71
Rate for Payer: Hawaii Medical Service Association Medicare	$7.92
Rate for Payer: Hawaii Western Management Group Commercial	$15.05
Rate for Payer: Health Management Network Commercial	$13.46
Rate for Payer: Humana Medicare	$7.92
Rate for Payer: Kaiser Permanente Commercial	$14.26
Rate for Payer: Kaiser Permanente Medicaid	$8.08
Rate for Payer: Kaiser Permanente Medicare	$7.92
Rate for Payer: MDX Hawaii PPO	$15.36
Rate for Payer: Ohana Health Plan Medicaid	$7.92
Rate for Payer: Ohana Health Plan Medicare	$7.92
Rate for Payer: UnitedHealthcare Medicaid	$9.50
Rate for Payer: UnitedHealthcare Medicare	$7.92
Rate for Payer: University Health Alliance Commercial	$11.55

sertraline 50 mg tablet [HHSC]

Facility

$15.84

Service Code	NDC 65862001201
Hospital Charge Code	2500738
Hospital Revenue Code	250
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$15.36
Rate for Payer: Cash Price	$10.30
Rate for Payer: Health Management Network Commercial	$13.46
Rate for Payer: Kaiser Permanente Commercial	$14.26
Rate for Payer: MDX Hawaii PPO	$15.36

SET 8.5F MULTI-PURPOSE DRAINAGE CATHETER (CT)

Facility

$741.00

Service Code	HCPCS C1729
Hospital Charge Code	8886988
Hospital Revenue Code	272
Min. Negotiated Rate	$370.50
Max. Negotiated Rate	$718.77
Rate for Payer: AlohaCare Medicaid	$370.50
Rate for Payer: AlohaCare Medicare	$370.50
Rate for Payer: Cash Price	$481.65
Rate for Payer: Devoted Health Medicare	$407.55
Rate for Payer: Hawaii Medical Service Association Medicare	$370.50
Rate for Payer: Hawaii Western Management Group Commercial	$703.95
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Humana Medicare	$370.50
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: Kaiser Permanente Medicaid	$377.91
Rate for Payer: Kaiser Permanente Medicare	$370.50
Rate for Payer: MDX Hawaii PPO	$718.77
Rate for Payer: Ohana Health Plan Medicaid	$370.50
Rate for Payer: Ohana Health Plan Medicare	$370.50
Rate for Payer: UnitedHealthcare Medicare	$370.50
Rate for Payer: University Health Alliance Commercial	$540.11

SET 8.5F MULTI-PURPOSE DRAINAGE CATHETER (CT)

Facility

$741.00

Service Code	HCPCS C1729
Hospital Charge Code	8886988
Hospital Revenue Code	272
Min. Negotiated Rate	$629.85
Max. Negotiated Rate	$718.77
Rate for Payer: Cash Price	$481.65
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: MDX Hawaii PPO	$718.77

SET 8.5F MULTI-PURPOSE DRAINAGE CATHETER (US)

Facility

$741.00

Service Code	HCPCS C1729
Hospital Charge Code	8886987
Hospital Revenue Code	272
Min. Negotiated Rate	$629.85
Max. Negotiated Rate	$718.77
Rate for Payer: Cash Price	$481.65
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: MDX Hawaii PPO	$718.77

SET 8.5F MULTI-PURPOSE DRAINAGE CATHETER (US)

Facility

$741.00

Service Code	HCPCS C1729
Hospital Charge Code	8886987
Hospital Revenue Code	272
Min. Negotiated Rate	$370.50
Max. Negotiated Rate	$718.77
Rate for Payer: AlohaCare Medicaid	$370.50
Rate for Payer: AlohaCare Medicare	$370.50
Rate for Payer: Cash Price	$481.65
Rate for Payer: Devoted Health Medicare	$407.55
Rate for Payer: Hawaii Medical Service Association Medicare	$370.50
Rate for Payer: Hawaii Western Management Group Commercial	$703.95
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Humana Medicare	$370.50
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: Kaiser Permanente Medicaid	$377.91
Rate for Payer: Kaiser Permanente Medicare	$370.50
Rate for Payer: MDX Hawaii PPO	$718.77
Rate for Payer: Ohana Health Plan Medicaid	$370.50
Rate for Payer: Ohana Health Plan Medicare	$370.50
Rate for Payer: UnitedHealthcare Medicare	$370.50
Rate for Payer: University Health Alliance Commercial	$540.11

SET 8.5F MULTI-PURPOSE DRAINAGE CATHETER (XR/MAMMO)

Facility

$741.00

Service Code	HCPCS C1729
Hospital Charge Code	8886989
Hospital Revenue Code	272
Min. Negotiated Rate	$370.50
Max. Negotiated Rate	$718.77
Rate for Payer: AlohaCare Medicaid	$370.50
Rate for Payer: AlohaCare Medicare	$370.50
Rate for Payer: Cash Price	$481.65
Rate for Payer: Devoted Health Medicare	$407.55
Rate for Payer: Hawaii Medical Service Association Medicare	$370.50
Rate for Payer: Hawaii Western Management Group Commercial	$703.95
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Humana Medicare	$370.50
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: Kaiser Permanente Medicaid	$377.91
Rate for Payer: Kaiser Permanente Medicare	$370.50
Rate for Payer: MDX Hawaii PPO	$718.77
Rate for Payer: Ohana Health Plan Medicaid	$370.50
Rate for Payer: Ohana Health Plan Medicare	$370.50
Rate for Payer: UnitedHealthcare Medicare	$370.50
Rate for Payer: University Health Alliance Commercial	$540.11

SET 8.5F MULTI-PURPOSE DRAINAGE CATHETER (XR/MAMMO)

Facility

$741.00

Service Code	HCPCS C1729
Hospital Charge Code	8886989
Hospital Revenue Code	272
Min. Negotiated Rate	$629.85
Max. Negotiated Rate	$718.77
Rate for Payer: Cash Price	$481.65
Rate for Payer: Health Management Network Commercial	$629.85
Rate for Payer: Kaiser Permanente Commercial	$666.90
Rate for Payer: MDX Hawaii PPO	$718.77

SET BELMONT 3 SPIKE BAG WITH RESERVOIR

Facility

$698.00

Hospital Charge Code	8716251
Hospital Revenue Code	272
Min. Negotiated Rate	$349.00
Max. Negotiated Rate	$677.06
Rate for Payer: AlohaCare Medicaid	$349.00
Rate for Payer: AlohaCare Medicare	$349.00
Rate for Payer: Cash Price	$453.70
Rate for Payer: Devoted Health Medicare	$383.90
Rate for Payer: Hawaii Medical Service Association Medicare	$349.00
Rate for Payer: Hawaii Western Management Group Commercial	$663.10
Rate for Payer: Health Management Network Commercial	$593.30
Rate for Payer: Humana Medicare	$349.00
Rate for Payer: Kaiser Permanente Commercial	$628.20
Rate for Payer: Kaiser Permanente Medicaid	$355.98
Rate for Payer: Kaiser Permanente Medicare	$349.00
Rate for Payer: MDX Hawaii PPO	$677.06
Rate for Payer: Ohana Health Plan Medicaid	$349.00
Rate for Payer: Ohana Health Plan Medicare	$349.00
Rate for Payer: UnitedHealthcare Medicare	$349.00
Rate for Payer: University Health Alliance Commercial	$508.77

SET BELMONT 3 SPIKE BAG WITH RESERVOIR

Facility

$698.00

Hospital Charge Code	8716251
Hospital Revenue Code	272
Min. Negotiated Rate	$593.30
Max. Negotiated Rate	$677.06
Rate for Payer: Cash Price	$453.70
Rate for Payer: Health Management Network Commercial	$593.30
Rate for Payer: Kaiser Permanente Commercial	$628.20
Rate for Payer: MDX Hawaii PPO	$677.06

SET EZ-IO 15MM NEEDLE+STABILIZER

Facility

$577.00

Hospital Charge Code	8500826
Hospital Revenue Code	272
Min. Negotiated Rate	$490.45
Max. Negotiated Rate	$559.69
Rate for Payer: Cash Price	$375.05
Rate for Payer: Health Management Network Commercial	$490.45
Rate for Payer: Kaiser Permanente Commercial	$519.30
Rate for Payer: MDX Hawaii PPO	$559.69

SET EZ-IO 15MM NEEDLE+STABILIZER

Facility

$577.00

Hospital Charge Code	8500826
Hospital Revenue Code	272
Min. Negotiated Rate	$288.50
Max. Negotiated Rate	$559.69
Rate for Payer: AlohaCare Medicaid	$288.50
Rate for Payer: AlohaCare Medicare	$288.50
Rate for Payer: Cash Price	$375.05
Rate for Payer: Devoted Health Medicare	$317.35
Rate for Payer: Hawaii Medical Service Association Medicare	$288.50
Rate for Payer: Hawaii Western Management Group Commercial	$548.15
Rate for Payer: Health Management Network Commercial	$490.45
Rate for Payer: Humana Medicare	$288.50
Rate for Payer: Kaiser Permanente Commercial	$519.30
Rate for Payer: Kaiser Permanente Medicaid	$294.27
Rate for Payer: Kaiser Permanente Medicare	$288.50
Rate for Payer: MDX Hawaii PPO	$559.69
Rate for Payer: Ohana Health Plan Medicaid	$288.50
Rate for Payer: Ohana Health Plan Medicare	$288.50
Rate for Payer: UnitedHealthcare Medicare	$288.50
Rate for Payer: University Health Alliance Commercial	$420.58

SET HSG CATHETER 5F (US)

Facility

$181.00

Hospital Charge Code	8890499
Hospital Revenue Code	272
Min. Negotiated Rate	$90.50
Max. Negotiated Rate	$175.57
Rate for Payer: AlohaCare Medicaid	$90.50
Rate for Payer: AlohaCare Medicare	$90.50
Rate for Payer: Cash Price	$117.65
Rate for Payer: Devoted Health Medicare	$99.55
Rate for Payer: Hawaii Medical Service Association Medicare	$90.50
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Humana Medicare	$90.50
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: Kaiser Permanente Medicare	$90.50
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: Ohana Health Plan Medicaid	$90.50
Rate for Payer: Ohana Health Plan Medicare	$90.50
Rate for Payer: UnitedHealthcare Medicare	$90.50
Rate for Payer: University Health Alliance Commercial	$131.93

SET HSG CATHETER 5F (US)

Facility

$181.00

Hospital Charge Code	8890499
Hospital Revenue Code	272
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$117.65
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: MDX Hawaii PPO	$175.57

SET HSG CATHETER 5F (XR/MAMMO)

Facility

$181.00

Hospital Charge Code	8890500
Hospital Revenue Code	272
Min. Negotiated Rate	$90.50
Max. Negotiated Rate	$175.57
Rate for Payer: AlohaCare Medicaid	$90.50
Rate for Payer: AlohaCare Medicare	$90.50
Rate for Payer: Cash Price	$117.65
Rate for Payer: Devoted Health Medicare	$99.55
Rate for Payer: Hawaii Medical Service Association Medicare	$90.50
Rate for Payer: Hawaii Western Management Group Commercial	$171.95
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Humana Medicare	$90.50
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: Kaiser Permanente Medicaid	$92.31
Rate for Payer: Kaiser Permanente Medicare	$90.50
Rate for Payer: MDX Hawaii PPO	$175.57
Rate for Payer: Ohana Health Plan Medicaid	$90.50
Rate for Payer: Ohana Health Plan Medicare	$90.50
Rate for Payer: UnitedHealthcare Medicare	$90.50
Rate for Payer: University Health Alliance Commercial	$131.93

SET HSG CATHETER 5F (XR/MAMMO)

Facility

$181.00

Hospital Charge Code	8890500
Hospital Revenue Code	272
Min. Negotiated Rate	$153.85
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$117.65
Rate for Payer: Health Management Network Commercial	$153.85
Rate for Payer: Kaiser Permanente Commercial	$162.90
Rate for Payer: MDX Hawaii PPO	$175.57

SET INTRO TIP PNEUMOTHORAX (CT)

Facility

$523.00

Hospital Charge Code	8890002
Hospital Revenue Code	272
Min. Negotiated Rate	$261.50
Max. Negotiated Rate	$507.31
Rate for Payer: AlohaCare Medicaid	$261.50
Rate for Payer: AlohaCare Medicare	$261.50
Rate for Payer: Cash Price	$339.95
Rate for Payer: Devoted Health Medicare	$287.65
Rate for Payer: Hawaii Medical Service Association Medicare	$261.50
Rate for Payer: Hawaii Western Management Group Commercial	$496.85
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Humana Medicare	$261.50
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: Kaiser Permanente Medicaid	$266.73
Rate for Payer: Kaiser Permanente Medicare	$261.50
Rate for Payer: MDX Hawaii PPO	$507.31
Rate for Payer: Ohana Health Plan Medicaid	$261.50
Rate for Payer: Ohana Health Plan Medicare	$261.50
Rate for Payer: UnitedHealthcare Medicare	$261.50
Rate for Payer: University Health Alliance Commercial	$381.21

Know your out-of-pocket cost for care.

All Charges