Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

sevelamer 800 mg tablet [HHSC]

Facility

$48.85

Service Code	NDC 68462044718
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$41.52
Max. Negotiated Rate	$47.38
Rate for Payer: Cash Price	$31.75
Rate for Payer: Health Management Network Commercial	$41.52
Rate for Payer: Kaiser Permanente Commercial	$43.97
Rate for Payer: MDX Hawaii PPO	$47.38

sevelamer 800 mg tablet [HHSC]

Facility

$53.14

Service Code	NDC 60687044901
Hospital Charge Code	2500739
Hospital Revenue Code	250
Min. Negotiated Rate	$45.17
Max. Negotiated Rate	$51.55
Rate for Payer: Cash Price	$34.54
Rate for Payer: Health Management Network Commercial	$45.17
Rate for Payer: Kaiser Permanente Commercial	$47.83
Rate for Payer: MDX Hawaii PPO	$51.55

sevoflurane 250 mL inhaltion gas [HHSC]

Facility

$183.59

Service Code	NDC 00074445604
Hospital Charge Code	2500740
Hospital Revenue Code	250
Min. Negotiated Rate	$156.05
Max. Negotiated Rate	$178.08
Rate for Payer: Cash Price	$119.33
Rate for Payer: Health Management Network Commercial	$156.05
Rate for Payer: Kaiser Permanente Commercial	$165.23
Rate for Payer: MDX Hawaii PPO	$178.08

sevoflurane 250 mL inhaltion gas [HHSC]

Facility

$295.85

Service Code	NDC 00074445651
Hospital Charge Code	2500740
Hospital Revenue Code	250
Min. Negotiated Rate	$147.93
Max. Negotiated Rate	$286.97
Rate for Payer: AlohaCare Medicaid	$147.93
Rate for Payer: AlohaCare Medicare	$147.93
Rate for Payer: Cash Price	$192.30
Rate for Payer: Devoted Health Medicare	$162.72
Rate for Payer: Hawaii Medical Service Association Medicare	$147.93
Rate for Payer: Hawaii Western Management Group Commercial	$281.06
Rate for Payer: Health Management Network Commercial	$251.47
Rate for Payer: Humana Medicare	$147.93
Rate for Payer: Kaiser Permanente Commercial	$266.26
Rate for Payer: Kaiser Permanente Medicaid	$150.88
Rate for Payer: Kaiser Permanente Medicare	$147.93
Rate for Payer: MDX Hawaii PPO	$286.97
Rate for Payer: Ohana Health Plan Medicaid	$147.93
Rate for Payer: Ohana Health Plan Medicare	$147.93
Rate for Payer: UnitedHealthcare Medicaid	$177.51
Rate for Payer: UnitedHealthcare Medicare	$147.93
Rate for Payer: University Health Alliance Commercial	$215.65

sevoflurane 250 mL inhaltion gas [HHSC]

Facility

$295.85

Service Code	NDC 00074445651
Hospital Charge Code	2500740
Hospital Revenue Code	250
Min. Negotiated Rate	$251.47
Max. Negotiated Rate	$286.97
Rate for Payer: Cash Price	$192.30
Rate for Payer: Health Management Network Commercial	$251.47
Rate for Payer: Kaiser Permanente Commercial	$266.26
Rate for Payer: MDX Hawaii PPO	$286.97

sevoflurane 250 mL inhaltion gas [HHSC]

Facility

$183.59

Service Code	NDC 00074445604
Hospital Charge Code	2500740
Hospital Revenue Code	250
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$178.08
Rate for Payer: AlohaCare Medicaid	$91.80
Rate for Payer: AlohaCare Medicare	$91.80
Rate for Payer: Cash Price	$119.33
Rate for Payer: Devoted Health Medicare	$100.97
Rate for Payer: Hawaii Medical Service Association Medicare	$91.80
Rate for Payer: Hawaii Western Management Group Commercial	$174.41
Rate for Payer: Health Management Network Commercial	$156.05
Rate for Payer: Humana Medicare	$91.80
Rate for Payer: Kaiser Permanente Commercial	$165.23
Rate for Payer: Kaiser Permanente Medicaid	$93.63
Rate for Payer: Kaiser Permanente Medicare	$91.80
Rate for Payer: MDX Hawaii PPO	$178.08
Rate for Payer: Ohana Health Plan Medicaid	$91.80
Rate for Payer: Ohana Health Plan Medicare	$91.80
Rate for Payer: UnitedHealthcare Medicaid	$110.15
Rate for Payer: UnitedHealthcare Medicare	$91.80
Rate for Payer: University Health Alliance Commercial	$133.82

Shiga Toxin Bill Only

Facility

$70.00

Hospital Charge Code	13128084
Hospital Revenue Code	306
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: MDX Hawaii PPO	$67.90

Shiga Toxin Bill Only

Facility

$70.00

Hospital Charge Code	13128084
Hospital Revenue Code	306
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$67.90
Rate for Payer: AlohaCare Medicaid	$35.00
Rate for Payer: AlohaCare Medicare	$35.00
Rate for Payer: Cash Price	$45.50
Rate for Payer: Devoted Health Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Medicare	$35.00
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Humana Medicare	$35.00
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: Kaiser Permanente Medicare	$35.00
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: Ohana Health Plan Medicaid	$35.00
Rate for Payer: Ohana Health Plan Medicare	$35.00
Rate for Payer: UnitedHealthcare Medicare	$35.00
Rate for Payer: University Health Alliance Commercial	$51.02

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$24,935.09

Service Code	MSDRG 511
Min. Negotiated Rate	$24,935.09
Max. Negotiated Rate	$24,935.09
Rate for Payer: Hawaii Medical Service Association Commercial	$24,935.09

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$24,935.09

Service Code	MSDRG 510
Min. Negotiated Rate	$24,935.09
Max. Negotiated Rate	$24,935.09
Rate for Payer: Hawaii Medical Service Association Commercial	$24,935.09

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$23,430.82

Service Code	MSDRG 512
Min. Negotiated Rate	$23,430.82
Max. Negotiated Rate	$23,430.82
Rate for Payer: Hawaii Medical Service Association Commercial	$23,430.82

Sickle Cell Solubility FSI

Facility

$77.00

Service Code	HCPCS 85660
Hospital Charge Code	8118045
Hospital Revenue Code	305
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$74.69
Rate for Payer: AlohaCare Medicaid	$38.50
Rate for Payer: AlohaCare Medicare	$38.50
Rate for Payer: Cash Price	$50.05
Rate for Payer: Cash Price	$50.05
Rate for Payer: Devoted Health Medicare	$42.35
Rate for Payer: Hawaii Medical Service Association ABD	$7.63
Rate for Payer: Hawaii Medical Service Association Commercial	$6.89
Rate for Payer: Hawaii Medical Service Association Medicare	$38.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.01
Rate for Payer: Hawaii Western Management Group Commercial	$5.51
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Humana Medicare	$38.50
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: Kaiser Permanente Medicare	$38.50
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: Ohana Health Plan Medicaid	$38.50
Rate for Payer: Ohana Health Plan Medicare	$38.50
Rate for Payer: UnitedHealthcare Medicaid	$7.63
Rate for Payer: UnitedHealthcare Medicare	$38.50
Rate for Payer: University Health Alliance Commercial	$14.26

Sickle Cell Solubility FSI

Facility

$77.00

Service Code	HCPCS 85660
Hospital Charge Code	8118045
Hospital Revenue Code	305
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$50.05
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: MDX Hawaii PPO	$74.69

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$11,294.73

Service Code	MSDRG 555
Min. Negotiated Rate	$11,294.73
Max. Negotiated Rate	$11,294.73
Rate for Payer: Hawaii Medical Service Association Commercial	$11,294.73

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$11,294.73

Service Code	MSDRG 556
Min. Negotiated Rate	$11,294.73
Max. Negotiated Rate	$11,294.73
Rate for Payer: Hawaii Medical Service Association Commercial	$11,294.73

SIGNS AND SYMPTOMS WITH MCC

Facility

$15,476.07

Service Code	MSDRG 947
Min. Negotiated Rate	$15,476.07
Max. Negotiated Rate	$15,476.07
Rate for Payer: Hawaii Medical Service Association Commercial	$15,476.07

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$14,711.19

Service Code	MSDRG 948
Min. Negotiated Rate	$14,711.19
Max. Negotiated Rate	$14,711.19
Rate for Payer: Hawaii Medical Service Association Commercial	$14,711.19

silver nitrate stick, topical [HHSC]

Facility

$3.97

Service Code	NDC 12870000101
Hospital Charge Code	2500741
Hospital Revenue Code	250
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$3.85
Rate for Payer: Cash Price	$2.58
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Kaiser Permanente Commercial	$3.57
Rate for Payer: MDX Hawaii PPO	$3.85

silver nitrate stick, topical [HHSC]

Facility

$3.97

Service Code	NDC 12870000101
Hospital Charge Code	2500741
Hospital Revenue Code	250
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$3.85
Rate for Payer: AlohaCare Medicaid	$1.99
Rate for Payer: AlohaCare Medicare	$1.99
Rate for Payer: Cash Price	$2.58
Rate for Payer: Devoted Health Medicare	$2.18
Rate for Payer: Hawaii Medical Service Association Medicare	$1.99
Rate for Payer: Hawaii Western Management Group Commercial	$3.77
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Humana Medicare	$1.99
Rate for Payer: Kaiser Permanente Commercial	$3.57
Rate for Payer: Kaiser Permanente Medicaid	$2.02
Rate for Payer: Kaiser Permanente Medicare	$1.99
Rate for Payer: MDX Hawaii PPO	$3.85
Rate for Payer: Ohana Health Plan Medicaid	$1.99
Rate for Payer: Ohana Health Plan Medicare	$1.99
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: UnitedHealthcare Medicare	$1.99
Rate for Payer: University Health Alliance Commercial	$2.89

silver sulfADIAZINE 1% 25gm cream [HHSC]

Facility

$53.46

Service Code	NDC 61570013125
Hospital Charge Code	2500744
Hospital Revenue Code	250
Min. Negotiated Rate	$45.44
Max. Negotiated Rate	$51.86
Rate for Payer: Cash Price	$34.75
Rate for Payer: Health Management Network Commercial	$45.44
Rate for Payer: Kaiser Permanente Commercial	$48.11
Rate for Payer: MDX Hawaii PPO	$51.86

silver sulfADIAZINE 1% 25gm cream [HHSC]

Facility

$53.85

Service Code	NDC 67877012425
Hospital Charge Code	2500744
Hospital Revenue Code	250
Min. Negotiated Rate	$45.77
Max. Negotiated Rate	$52.23
Rate for Payer: Cash Price	$35.00
Rate for Payer: Health Management Network Commercial	$45.77
Rate for Payer: Kaiser Permanente Commercial	$48.47
Rate for Payer: MDX Hawaii PPO	$52.23

silver sulfADIAZINE 1% 25gm cream [HHSC]

Facility

$53.46

Service Code	NDC 43598021025
Hospital Charge Code	2500744
Hospital Revenue Code	250
Min. Negotiated Rate	$26.73
Max. Negotiated Rate	$51.86
Rate for Payer: AlohaCare Medicaid	$26.73
Rate for Payer: AlohaCare Medicare	$26.73
Rate for Payer: Cash Price	$34.75
Rate for Payer: Devoted Health Medicare	$29.40
Rate for Payer: Hawaii Medical Service Association Medicare	$26.73
Rate for Payer: Hawaii Western Management Group Commercial	$50.79
Rate for Payer: Health Management Network Commercial	$45.44
Rate for Payer: Humana Medicare	$26.73
Rate for Payer: Kaiser Permanente Commercial	$48.11
Rate for Payer: Kaiser Permanente Medicaid	$27.26
Rate for Payer: Kaiser Permanente Medicare	$26.73
Rate for Payer: MDX Hawaii PPO	$51.86
Rate for Payer: Ohana Health Plan Medicaid	$26.73
Rate for Payer: Ohana Health Plan Medicare	$26.73
Rate for Payer: UnitedHealthcare Medicaid	$32.08
Rate for Payer: UnitedHealthcare Medicare	$26.73
Rate for Payer: University Health Alliance Commercial	$38.97

silver sulfADIAZINE 1% 25gm cream [HHSC]

Facility

$53.85

Service Code	NDC 67877012425
Hospital Charge Code	2500744
Hospital Revenue Code	250
Min. Negotiated Rate	$26.93
Max. Negotiated Rate	$52.23
Rate for Payer: AlohaCare Medicaid	$26.93
Rate for Payer: AlohaCare Medicare	$26.93
Rate for Payer: Cash Price	$35.00
Rate for Payer: Devoted Health Medicare	$29.62
Rate for Payer: Hawaii Medical Service Association Medicare	$26.93
Rate for Payer: Hawaii Western Management Group Commercial	$51.16
Rate for Payer: Health Management Network Commercial	$45.77
Rate for Payer: Humana Medicare	$26.93
Rate for Payer: Kaiser Permanente Commercial	$48.47
Rate for Payer: Kaiser Permanente Medicaid	$27.46
Rate for Payer: Kaiser Permanente Medicare	$26.93
Rate for Payer: MDX Hawaii PPO	$52.23
Rate for Payer: Ohana Health Plan Medicaid	$26.93
Rate for Payer: Ohana Health Plan Medicare	$26.93
Rate for Payer: UnitedHealthcare Medicaid	$32.31
Rate for Payer: UnitedHealthcare Medicare	$26.93
Rate for Payer: University Health Alliance Commercial	$39.25

silver sulfADIAZINE 1% 25gm cream [HHSC]

Facility

$53.46

Service Code	NDC 61570013125
Hospital Charge Code	2500744
Hospital Revenue Code	250
Min. Negotiated Rate	$26.73
Max. Negotiated Rate	$51.86
Rate for Payer: AlohaCare Medicaid	$26.73
Rate for Payer: AlohaCare Medicare	$26.73
Rate for Payer: Cash Price	$34.75
Rate for Payer: Devoted Health Medicare	$29.40
Rate for Payer: Hawaii Medical Service Association Medicare	$26.73
Rate for Payer: Hawaii Western Management Group Commercial	$50.79
Rate for Payer: Health Management Network Commercial	$45.44
Rate for Payer: Humana Medicare	$26.73
Rate for Payer: Kaiser Permanente Commercial	$48.11
Rate for Payer: Kaiser Permanente Medicaid	$27.26
Rate for Payer: Kaiser Permanente Medicare	$26.73
Rate for Payer: MDX Hawaii PPO	$51.86
Rate for Payer: Ohana Health Plan Medicaid	$26.73
Rate for Payer: Ohana Health Plan Medicare	$26.73
Rate for Payer: UnitedHealthcare Medicaid	$32.08
Rate for Payer: UnitedHealthcare Medicare	$26.73
Rate for Payer: University Health Alliance Commercial	$38.97

silver sulfADIAZINE 1% 25gm cream [HHSC]

Facility

$53.46

Service Code	NDC 43598021025
Hospital Charge Code	2500744
Hospital Revenue Code	250
Min. Negotiated Rate	$45.44
Max. Negotiated Rate	$51.86
Rate for Payer: Cash Price	$34.75
Rate for Payer: Health Management Network Commercial	$45.44
Rate for Payer: Kaiser Permanente Commercial	$48.11
Rate for Payer: MDX Hawaii PPO	$51.86

Know your out-of-pocket cost for care.

All Charges