Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

SET INTRO TIP PNEUMOTHORAX (CT)

Facility

$523.00

Hospital Charge Code	8890002
Hospital Revenue Code	272
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$339.95
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: MDX Hawaii PPO	$507.31

SET INTRO TIP PNEUMOTHORAX (US)

Facility

$523.00

Hospital Charge Code	8890001
Hospital Revenue Code	272
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$339.95
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: MDX Hawaii PPO	$507.31

SET INTRO TIP PNEUMOTHORAX (US)

Facility

$523.00

Hospital Charge Code	8890001
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

SET INTRO TIP PNEUMOTHORAX (XR/MAMMO)

Facility

$449.00

Hospital Charge Code	8890003
Hospital Revenue Code	272
Min. Negotiated Rate	$224.50
Max. Negotiated Rate	$435.53
Rate for Payer: AlohaCare Medicaid	$224.50
Rate for Payer: AlohaCare Medicare	$224.50
Rate for Payer: Cash Price	$291.85
Rate for Payer: Devoted Health Medicare	$246.95
Rate for Payer: Hawaii Medical Service Association Medicare	$224.50
Rate for Payer: Hawaii Western Management Group Commercial	$426.55
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Humana Medicare	$224.50
Rate for Payer: Kaiser Permanente Commercial	$404.10
Rate for Payer: Kaiser Permanente Medicaid	$228.99
Rate for Payer: Kaiser Permanente Medicare	$224.50
Rate for Payer: MDX Hawaii PPO	$435.53
Rate for Payer: Ohana Health Plan Medicaid	$224.50
Rate for Payer: Ohana Health Plan Medicare	$224.50
Rate for Payer: UnitedHealthcare Medicare	$224.50
Rate for Payer: University Health Alliance Commercial	$327.28

SET INTRO TIP PNEUMOTHORAX (XR/MAMMO)

Facility

$449.00

Hospital Charge Code	8890003
Hospital Revenue Code	272
Min. Negotiated Rate	$381.65
Max. Negotiated Rate	$435.53
Rate for Payer: Cash Price	$291.85
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Kaiser Permanente Commercial	$404.10
Rate for Payer: MDX Hawaii PPO	$435.53

SET MULTI-PURPOSE DRAINAGE 12FR

Facility

$746.00

Hospital Charge Code	10189804
Hospital Revenue Code	272
Min. Negotiated Rate	$634.10
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$484.90
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: MDX Hawaii PPO	$723.62

SET MULTI-PURPOSE DRAINAGE 12FR

Facility

$746.00

Hospital Charge Code	10189804
Hospital Revenue Code	272
Min. Negotiated Rate	$373.00
Max. Negotiated Rate	$723.62
Rate for Payer: AlohaCare Medicaid	$373.00
Rate for Payer: AlohaCare Medicare	$373.00
Rate for Payer: Cash Price	$484.90
Rate for Payer: Devoted Health Medicare	$410.30
Rate for Payer: Hawaii Medical Service Association Medicare	$373.00
Rate for Payer: Hawaii Western Management Group Commercial	$708.70
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Humana Medicare	$373.00
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: Kaiser Permanente Medicaid	$380.46
Rate for Payer: Kaiser Permanente Medicare	$373.00
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: Ohana Health Plan Medicaid	$373.00
Rate for Payer: Ohana Health Plan Medicare	$373.00
Rate for Payer: UnitedHealthcare Medicare	$373.00
Rate for Payer: University Health Alliance Commercial	$543.76

SET PNEUMOCLEAR SMOKE EVACUATION HIGH FLOW INSUFFLATOR TUBE

Facility

$228.00

Hospital Charge Code	8879043
Hospital Revenue Code	272
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$221.16
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: MDX Hawaii PPO	$221.16

SET PNEUMOCLEAR SMOKE EVACUATION HIGH FLOW INSUFFLATOR TUBE

Facility

$228.00

Hospital Charge Code	8879043
Hospital Revenue Code	272
Min. Negotiated Rate	$114.00
Max. Negotiated Rate	$221.16
Rate for Payer: AlohaCare Medicaid	$114.00
Rate for Payer: AlohaCare Medicare	$114.00
Rate for Payer: Cash Price	$148.20
Rate for Payer: Devoted Health Medicare	$125.40
Rate for Payer: Hawaii Medical Service Association Medicare	$114.00
Rate for Payer: Hawaii Western Management Group Commercial	$216.60
Rate for Payer: Health Management Network Commercial	$193.80
Rate for Payer: Humana Medicare	$114.00
Rate for Payer: Kaiser Permanente Commercial	$205.20
Rate for Payer: Kaiser Permanente Medicaid	$116.28
Rate for Payer: Kaiser Permanente Medicare	$114.00
Rate for Payer: MDX Hawaii PPO	$221.16
Rate for Payer: Ohana Health Plan Medicaid	$114.00
Rate for Payer: Ohana Health Plan Medicare	$114.00
Rate for Payer: UnitedHealthcare Medicare	$114.00
Rate for Payer: University Health Alliance Commercial	$166.19

SET RADIAL ARTERY CATHERIZATION

Facility

$133.00

Hospital Charge Code	8266662
Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$86.45
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: MDX Hawaii PPO	$129.01

SET RADIAL ARTERY CATHERIZATION

Facility

$133.00

Hospital Charge Code	8266662
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$129.01
Rate for Payer: AlohaCare Medicaid	$66.50
Rate for Payer: AlohaCare Medicare	$66.50
Rate for Payer: Cash Price	$86.45
Rate for Payer: Devoted Health Medicare	$73.15
Rate for Payer: Hawaii Medical Service Association Medicare	$66.50
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Humana Medicare	$66.50
Rate for Payer: Kaiser Permanente Commercial	$119.70
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: Kaiser Permanente Medicare	$66.50
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: Ohana Health Plan Medicaid	$66.50
Rate for Payer: Ohana Health Plan Medicare	$66.50
Rate for Payer: UnitedHealthcare Medicare	$66.50
Rate for Payer: University Health Alliance Commercial	$96.94

SET UNIVERSAL CURVED DRAINAGE CATHETER (CT)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890005
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

SET UNIVERSAL CURVED DRAINAGE CATHETER (CT)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890005
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

SET UNIVERSAL CURVED DRAINAGE CATHETER (US)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890004
Hospital Revenue Code	272
Min. Negotiated Rate	$300.90
Max. Negotiated Rate	$343.38
Rate for Payer: Cash Price	$230.10
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: MDX Hawaii PPO	$343.38

SET UNIVERSAL CURVED DRAINAGE CATHETER (US)

Facility

$354.00

Service Code	HCPCS C1729
Hospital Charge Code	8890004
Hospital Revenue Code	272
Min. Negotiated Rate	$177.00
Max. Negotiated Rate	$343.38
Rate for Payer: AlohaCare Medicaid	$177.00
Rate for Payer: AlohaCare Medicare	$177.00
Rate for Payer: Cash Price	$230.10
Rate for Payer: Devoted Health Medicare	$194.70
Rate for Payer: Hawaii Medical Service Association Medicare	$177.00
Rate for Payer: Hawaii Western Management Group Commercial	$336.30
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Humana Medicare	$177.00
Rate for Payer: Kaiser Permanente Commercial	$318.60
Rate for Payer: Kaiser Permanente Medicaid	$180.54
Rate for Payer: Kaiser Permanente Medicare	$177.00
Rate for Payer: MDX Hawaii PPO	$343.38
Rate for Payer: Ohana Health Plan Medicaid	$177.00
Rate for Payer: Ohana Health Plan Medicare	$177.00
Rate for Payer: UnitedHealthcare Medicare	$177.00
Rate for Payer: University Health Alliance Commercial	$258.03

SET UNIVERSAL CURVED DRAINAGE CATHETER (XR/MAMMO)

Facility

$301.00

Service Code	HCPCS C1729
Hospital Charge Code	8890006
Hospital Revenue Code	272
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$291.97
Rate for Payer: AlohaCare Medicaid	$150.50
Rate for Payer: AlohaCare Medicare	$150.50
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$165.55
Rate for Payer: Hawaii Medical Service Association Medicare	$150.50
Rate for Payer: Hawaii Western Management Group Commercial	$285.95
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Humana Medicare	$150.50
Rate for Payer: Kaiser Permanente Commercial	$270.90
Rate for Payer: Kaiser Permanente Medicaid	$153.51
Rate for Payer: Kaiser Permanente Medicare	$150.50
Rate for Payer: MDX Hawaii PPO	$291.97
Rate for Payer: Ohana Health Plan Medicaid	$150.50
Rate for Payer: Ohana Health Plan Medicare	$150.50
Rate for Payer: UnitedHealthcare Medicare	$150.50
Rate for Payer: University Health Alliance Commercial	$219.40

SET UNIVERSAL CURVED DRAINAGE CATHETER (XR/MAMMO)

Facility

$301.00

Service Code	HCPCS C1729
Hospital Charge Code	8890006
Hospital Revenue Code	272
Min. Negotiated Rate	$255.85
Max. Negotiated Rate	$291.97
Rate for Payer: Cash Price	$195.65
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$270.90
Rate for Payer: MDX Hawaii PPO	$291.97

SET UROLOGY IRRIGATION T-U-R Y-SET

Facility

$82.00

Service Code	HCPCS A4355
Hospital Charge Code	8879103
Hospital Revenue Code	272
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$53.30
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: MDX Hawaii PPO	$79.54

SET UROLOGY IRRIGATION T-U-R Y-SET

Facility

$82.00

Service Code	HCPCS A4355
Hospital Charge Code	8879103
Hospital Revenue Code	272
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$79.54
Rate for Payer: AlohaCare Medicaid	$41.00
Rate for Payer: AlohaCare Medicare	$41.00
Rate for Payer: Cash Price	$53.30
Rate for Payer: Cash Price	$53.30
Rate for Payer: Devoted Health Medicare	$45.10
Rate for Payer: Hawaii Medical Service Association Medicare	$41.00
Rate for Payer: Hawaii Western Management Group Commercial	$77.90
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Humana Medicare	$41.00
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: Kaiser Permanente Medicare	$41.00
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: Ohana Health Plan Medicaid	$41.00
Rate for Payer: Ohana Health Plan Medicare	$41.00
Rate for Payer: UnitedHealthcare Medicaid	$7.02
Rate for Payer: UnitedHealthcare Medicare	$41.00
Rate for Payer: University Health Alliance Commercial	$59.77

sevelamer 800 mg tablet [HHSC]

Facility

$50.92

Service Code	NDC 58468002101
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$25.46
Max. Negotiated Rate	$49.39
Rate for Payer: AlohaCare Medicaid	$25.46
Rate for Payer: AlohaCare Medicare	$25.46
Rate for Payer: Cash Price	$33.10
Rate for Payer: Devoted Health Medicare	$28.01
Rate for Payer: Hawaii Medical Service Association Medicare	$25.46
Rate for Payer: Hawaii Western Management Group Commercial	$48.37
Rate for Payer: Health Management Network Commercial	$43.28
Rate for Payer: Humana Medicare	$25.46
Rate for Payer: Kaiser Permanente Commercial	$45.83
Rate for Payer: Kaiser Permanente Medicaid	$25.97
Rate for Payer: Kaiser Permanente Medicare	$25.46
Rate for Payer: MDX Hawaii PPO	$49.39
Rate for Payer: Ohana Health Plan Medicaid	$25.46
Rate for Payer: Ohana Health Plan Medicare	$25.46
Rate for Payer: UnitedHealthcare Medicaid	$30.55
Rate for Payer: UnitedHealthcare Medicare	$25.46
Rate for Payer: University Health Alliance Commercial	$37.12

sevelamer 800 mg tablet [HHSC]

Facility

$53.14

Service Code	NDC 60687044901
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$26.57
Max. Negotiated Rate	$51.55
Rate for Payer: AlohaCare Medicaid	$26.57
Rate for Payer: AlohaCare Medicare	$26.57
Rate for Payer: Cash Price	$34.54
Rate for Payer: Devoted Health Medicare	$29.23
Rate for Payer: Hawaii Medical Service Association Medicare	$26.57
Rate for Payer: Hawaii Western Management Group Commercial	$50.48
Rate for Payer: Health Management Network Commercial	$45.17
Rate for Payer: Humana Medicare	$26.57
Rate for Payer: Kaiser Permanente Commercial	$47.83
Rate for Payer: Kaiser Permanente Medicaid	$27.10
Rate for Payer: Kaiser Permanente Medicare	$26.57
Rate for Payer: MDX Hawaii PPO	$51.55
Rate for Payer: Ohana Health Plan Medicaid	$26.57
Rate for Payer: Ohana Health Plan Medicare	$26.57
Rate for Payer: UnitedHealthcare Medicaid	$31.88
Rate for Payer: UnitedHealthcare Medicare	$26.57
Rate for Payer: University Health Alliance Commercial	$38.73

sevelamer 800 mg tablet [HHSC]

Facility

$44.74

Service Code	NDC 00955104818
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$38.03
Max. Negotiated Rate	$43.40
Rate for Payer: Cash Price	$29.08
Rate for Payer: Health Management Network Commercial	$38.03
Rate for Payer: Kaiser Permanente Commercial	$40.27
Rate for Payer: MDX Hawaii PPO	$43.40

sevelamer 800 mg tablet [HHSC]

Facility

$44.74

Service Code	NDC 00955104818
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$43.40
Rate for Payer: AlohaCare Medicaid	$22.37
Rate for Payer: AlohaCare Medicare	$22.37
Rate for Payer: Cash Price	$29.08
Rate for Payer: Devoted Health Medicare	$24.61
Rate for Payer: Hawaii Medical Service Association Medicare	$22.37
Rate for Payer: Hawaii Western Management Group Commercial	$42.50
Rate for Payer: Health Management Network Commercial	$38.03
Rate for Payer: Humana Medicare	$22.37
Rate for Payer: Kaiser Permanente Commercial	$40.27
Rate for Payer: Kaiser Permanente Medicaid	$22.82
Rate for Payer: Kaiser Permanente Medicare	$22.37
Rate for Payer: MDX Hawaii PPO	$43.40
Rate for Payer: Ohana Health Plan Medicaid	$22.37
Rate for Payer: Ohana Health Plan Medicare	$22.37
Rate for Payer: UnitedHealthcare Medicaid	$26.84
Rate for Payer: UnitedHealthcare Medicare	$22.37
Rate for Payer: University Health Alliance Commercial	$32.61

sevelamer 800 mg tablet [HHSC]

Facility

$50.92

Service Code	NDC 58468002101
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$43.28
Max. Negotiated Rate	$49.39
Rate for Payer: Cash Price	$33.10
Rate for Payer: Health Management Network Commercial	$43.28
Rate for Payer: Kaiser Permanente Commercial	$45.83
Rate for Payer: MDX Hawaii PPO	$49.39

sevelamer 800 mg tablet [HHSC]

Facility

$48.85

Service Code	NDC 68462044718
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$24.43
Max. Negotiated Rate	$47.38
Rate for Payer: AlohaCare Medicaid	$24.43
Rate for Payer: AlohaCare Medicare	$24.43
Rate for Payer: Cash Price	$31.75
Rate for Payer: Devoted Health Medicare	$26.87
Rate for Payer: Hawaii Medical Service Association Medicare	$24.43
Rate for Payer: Hawaii Western Management Group Commercial	$46.41
Rate for Payer: Health Management Network Commercial	$41.52
Rate for Payer: Humana Medicare	$24.43
Rate for Payer: Kaiser Permanente Commercial	$43.97
Rate for Payer: Kaiser Permanente Medicaid	$24.91
Rate for Payer: Kaiser Permanente Medicare	$24.43
Rate for Payer: MDX Hawaii PPO	$47.38
Rate for Payer: Ohana Health Plan Medicaid	$24.43
Rate for Payer: Ohana Health Plan Medicare	$24.43
Rate for Payer: UnitedHealthcare Medicaid	$29.31
Rate for Payer: UnitedHealthcare Medicare	$24.43
Rate for Payer: University Health Alliance Commercial	$35.61

Know your out-of-pocket cost for care.

All Charges