Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

silver sulfADIAZINE 1% 85gm cream [HHSC]

Facility

$132.06

Service Code	NDC 67877012485
Hospital Charge Code	2500743
Hospital Revenue Code	250
Min. Negotiated Rate	$112.25
Max. Negotiated Rate	$128.10
Rate for Payer: Cash Price	$85.84
Rate for Payer: Health Management Network Commercial	$112.25
Rate for Payer: Kaiser Permanente Commercial	$118.85
Rate for Payer: MDX Hawaii PPO	$128.10

silver sulfADIAZINE 1% 85gm cream [HHSC]

Facility

$128.79

Service Code	NDC 43598021085
Hospital Charge Code	2500743
Hospital Revenue Code	250
Min. Negotiated Rate	$64.39
Max. Negotiated Rate	$124.93
Rate for Payer: AlohaCare Medicaid	$64.39
Rate for Payer: AlohaCare Medicare	$64.39
Rate for Payer: Cash Price	$83.71
Rate for Payer: Devoted Health Medicare	$70.83
Rate for Payer: Hawaii Medical Service Association Medicare	$64.39
Rate for Payer: Hawaii Western Management Group Commercial	$122.35
Rate for Payer: Health Management Network Commercial	$109.47
Rate for Payer: Humana Medicare	$64.39
Rate for Payer: Kaiser Permanente Commercial	$115.91
Rate for Payer: Kaiser Permanente Medicaid	$65.68
Rate for Payer: Kaiser Permanente Medicare	$64.39
Rate for Payer: MDX Hawaii PPO	$124.93
Rate for Payer: Ohana Health Plan Medicaid	$64.39
Rate for Payer: Ohana Health Plan Medicare	$64.39
Rate for Payer: UnitedHealthcare Medicaid	$77.27
Rate for Payer: UnitedHealthcare Medicare	$64.39
Rate for Payer: University Health Alliance Commercial	$93.88

silver sulfADIAZINE 1% 85gm cream [HHSC]

Facility

$137.71

Service Code	NDC 61570013185
Hospital Charge Code	2500743
Hospital Revenue Code	250
Min. Negotiated Rate	$117.05
Max. Negotiated Rate	$133.58
Rate for Payer: Cash Price	$89.51
Rate for Payer: Health Management Network Commercial	$117.05
Rate for Payer: Kaiser Permanente Commercial	$123.94
Rate for Payer: MDX Hawaii PPO	$133.58

silver sulfADIAZINE 1% 85gm cream [HHSC]

Facility

$132.06

Service Code	NDC 67877012485
Hospital Charge Code	2500743
Hospital Revenue Code	250
Min. Negotiated Rate	$66.03
Max. Negotiated Rate	$128.10
Rate for Payer: AlohaCare Medicaid	$66.03
Rate for Payer: AlohaCare Medicare	$66.03
Rate for Payer: Cash Price	$85.84
Rate for Payer: Devoted Health Medicare	$72.63
Rate for Payer: Hawaii Medical Service Association Medicare	$66.03
Rate for Payer: Hawaii Western Management Group Commercial	$125.46
Rate for Payer: Health Management Network Commercial	$112.25
Rate for Payer: Humana Medicare	$66.03
Rate for Payer: Kaiser Permanente Commercial	$118.85
Rate for Payer: Kaiser Permanente Medicaid	$67.35
Rate for Payer: Kaiser Permanente Medicare	$66.03
Rate for Payer: MDX Hawaii PPO	$128.10
Rate for Payer: Ohana Health Plan Medicaid	$66.03
Rate for Payer: Ohana Health Plan Medicare	$66.03
Rate for Payer: UnitedHealthcare Medicaid	$79.24
Rate for Payer: UnitedHealthcare Medicare	$66.03
Rate for Payer: University Health Alliance Commercial	$96.26

silver sulfADIAZINE 1% 85gm cream [HHSC]

Facility

$137.71

Service Code	NDC 61570013185
Hospital Charge Code	2500743
Hospital Revenue Code	250
Min. Negotiated Rate	$68.86
Max. Negotiated Rate	$133.58
Rate for Payer: AlohaCare Medicaid	$68.86
Rate for Payer: AlohaCare Medicare	$68.86
Rate for Payer: Cash Price	$89.51
Rate for Payer: Devoted Health Medicare	$75.74
Rate for Payer: Hawaii Medical Service Association Medicare	$68.86
Rate for Payer: Hawaii Western Management Group Commercial	$130.82
Rate for Payer: Health Management Network Commercial	$117.05
Rate for Payer: Humana Medicare	$68.86
Rate for Payer: Kaiser Permanente Commercial	$123.94
Rate for Payer: Kaiser Permanente Medicaid	$70.23
Rate for Payer: Kaiser Permanente Medicare	$68.86
Rate for Payer: MDX Hawaii PPO	$133.58
Rate for Payer: Ohana Health Plan Medicaid	$68.86
Rate for Payer: Ohana Health Plan Medicare	$68.86
Rate for Payer: UnitedHealthcare Medicaid	$82.63
Rate for Payer: UnitedHealthcare Medicare	$68.86
Rate for Payer: University Health Alliance Commercial	$100.38

silver sulfADIAZINE 1% 85gm cream [HHSC]

Facility

$128.79

Service Code	NDC 43598021085
Hospital Charge Code	2500743
Hospital Revenue Code	250
Min. Negotiated Rate	$109.47
Max. Negotiated Rate	$124.93
Rate for Payer: Cash Price	$83.71
Rate for Payer: Health Management Network Commercial	$109.47
Rate for Payer: Kaiser Permanente Commercial	$115.91
Rate for Payer: MDX Hawaii PPO	$124.93

silver sulfADIAZINE Top 1% Crm 400g [HHSC]

Facility

$321.72

Service Code	NDC 43598021040
Hospital Charge Code	2500742
Hospital Revenue Code	250
Min. Negotiated Rate	$160.86
Max. Negotiated Rate	$312.07
Rate for Payer: AlohaCare Medicaid	$160.86
Rate for Payer: AlohaCare Medicare	$160.86
Rate for Payer: Cash Price	$209.12
Rate for Payer: Devoted Health Medicare	$176.95
Rate for Payer: Hawaii Medical Service Association Medicare	$160.86
Rate for Payer: Hawaii Western Management Group Commercial	$305.63
Rate for Payer: Health Management Network Commercial	$273.46
Rate for Payer: Humana Medicare	$160.86
Rate for Payer: Kaiser Permanente Commercial	$289.55
Rate for Payer: Kaiser Permanente Medicaid	$164.08
Rate for Payer: Kaiser Permanente Medicare	$160.86
Rate for Payer: MDX Hawaii PPO	$312.07
Rate for Payer: Ohana Health Plan Medicaid	$160.86
Rate for Payer: Ohana Health Plan Medicare	$160.86
Rate for Payer: UnitedHealthcare Medicaid	$193.03
Rate for Payer: UnitedHealthcare Medicare	$160.86
Rate for Payer: University Health Alliance Commercial	$234.50

silver sulfADIAZINE Top 1% Crm 400g [HHSC]

Facility

$326.46

Service Code	NDC 67877012440
Hospital Charge Code	2500742
Hospital Revenue Code	250
Min. Negotiated Rate	$277.49
Max. Negotiated Rate	$316.67
Rate for Payer: Cash Price	$212.20
Rate for Payer: Health Management Network Commercial	$277.49
Rate for Payer: Kaiser Permanente Commercial	$293.81
Rate for Payer: MDX Hawaii PPO	$316.67

silver sulfADIAZINE Top 1% Crm 400g [HHSC]

Facility

$326.46

Service Code	NDC 67877012440
Hospital Charge Code	2500742
Hospital Revenue Code	250
Min. Negotiated Rate	$163.23
Max. Negotiated Rate	$316.67
Rate for Payer: AlohaCare Medicaid	$163.23
Rate for Payer: AlohaCare Medicare	$163.23
Rate for Payer: Cash Price	$212.20
Rate for Payer: Devoted Health Medicare	$179.55
Rate for Payer: Hawaii Medical Service Association Medicare	$163.23
Rate for Payer: Hawaii Western Management Group Commercial	$310.14
Rate for Payer: Health Management Network Commercial	$277.49
Rate for Payer: Humana Medicare	$163.23
Rate for Payer: Kaiser Permanente Commercial	$293.81
Rate for Payer: Kaiser Permanente Medicaid	$166.49
Rate for Payer: Kaiser Permanente Medicare	$163.23
Rate for Payer: MDX Hawaii PPO	$316.67
Rate for Payer: Ohana Health Plan Medicaid	$163.23
Rate for Payer: Ohana Health Plan Medicare	$163.23
Rate for Payer: UnitedHealthcare Medicaid	$195.88
Rate for Payer: UnitedHealthcare Medicare	$163.23
Rate for Payer: University Health Alliance Commercial	$237.96

silver sulfADIAZINE Top 1% Crm 400g [HHSC]

Facility

$346.31

Service Code	NDC 61570013140
Hospital Charge Code	2500742
Hospital Revenue Code	250
Min. Negotiated Rate	$173.16
Max. Negotiated Rate	$335.92
Rate for Payer: AlohaCare Medicaid	$173.16
Rate for Payer: AlohaCare Medicare	$173.16
Rate for Payer: Cash Price	$225.10
Rate for Payer: Devoted Health Medicare	$190.47
Rate for Payer: Hawaii Medical Service Association Medicare	$173.16
Rate for Payer: Hawaii Western Management Group Commercial	$328.99
Rate for Payer: Health Management Network Commercial	$294.36
Rate for Payer: Humana Medicare	$173.16
Rate for Payer: Kaiser Permanente Commercial	$311.68
Rate for Payer: Kaiser Permanente Medicaid	$176.62
Rate for Payer: Kaiser Permanente Medicare	$173.16
Rate for Payer: MDX Hawaii PPO	$335.92
Rate for Payer: Ohana Health Plan Medicaid	$173.16
Rate for Payer: Ohana Health Plan Medicare	$173.16
Rate for Payer: UnitedHealthcare Medicaid	$207.79
Rate for Payer: UnitedHealthcare Medicare	$173.16
Rate for Payer: University Health Alliance Commercial	$252.43

silver sulfADIAZINE Top 1% Crm 400g [HHSC]

Facility

$346.31

Service Code	NDC 61570013140
Hospital Charge Code	2500742
Hospital Revenue Code	250
Min. Negotiated Rate	$294.36
Max. Negotiated Rate	$335.92
Rate for Payer: Cash Price	$225.10
Rate for Payer: Health Management Network Commercial	$294.36
Rate for Payer: Kaiser Permanente Commercial	$311.68
Rate for Payer: MDX Hawaii PPO	$335.92

silver sulfADIAZINE Top 1% Crm 400g [HHSC]

Facility

$321.72

Service Code	NDC 43598021040
Hospital Charge Code	2500742
Hospital Revenue Code	250
Min. Negotiated Rate	$273.46
Max. Negotiated Rate	$312.07
Rate for Payer: Cash Price	$209.12
Rate for Payer: Health Management Network Commercial	$273.46
Rate for Payer: Kaiser Permanente Commercial	$289.55
Rate for Payer: MDX Hawaii PPO	$312.07

simethicone 40 mg/0.6 mL susp [HHSC]

Facility

$7.50

Service Code	HCPCS A9270
Hospital Charge Code	2501047
Hospital Revenue Code	250
Min. Negotiated Rate	$6.38
Max. Negotiated Rate	$7.28
Rate for Payer: Cash Price	$4.88
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$6.38
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$6.75
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: MDX Hawaii PPO	$7.28

simethicone 40 mg/0.6 mL susp [HHSC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Charge Code	2501047
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicaid	$3.75
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: AlohaCare Medicare	$3.75
Rate for Payer: Cash Price	$4.88
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Devoted Health Medicare	$4.12
Rate for Payer: Hawaii Medical Service Association Medicare	$3.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$7.12
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$6.38
Rate for Payer: Humana Medicare	$3.75
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Commercial	$6.75
Rate for Payer: Kaiser Permanente Medicaid	$3.83
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$3.75
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$7.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicaid	$3.75
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: Ohana Health Plan Medicare	$3.75
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicare	$3.75
Rate for Payer: University Health Alliance Commercial	$5.47
Rate for Payer: University Health Alliance Commercial	$2.19

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 63739022510
Hospital Charge Code	2500746
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

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 63739022510
Hospital Charge Code	2500746
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

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333081210
Hospital Charge Code	2500746
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

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 24385011878
Hospital Charge Code	2500746
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

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904506860
Hospital Charge Code	2500746
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

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 24385011878
Hospital Charge Code	2500746
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

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333081210
Hospital Charge Code	2500746
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

simethicone 80 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904506860
Hospital Charge Code	2500746
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

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$25,597.98

Service Code	MSDRG 194
Min. Negotiated Rate	$25,597.98
Max. Negotiated Rate	$25,597.98
Rate for Payer: Hawaii Medical Service Association Commercial	$25,597.98

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$26,490.34

Service Code	MSDRG 193
Min. Negotiated Rate	$26,490.34
Max. Negotiated Rate	$26,490.34
Rate for Payer: Hawaii Medical Service Association Commercial	$26,490.34

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$20,371.30

Service Code	MSDRG 195
Min. Negotiated Rate	$20,371.30
Max. Negotiated Rate	$20,371.30
Rate for Payer: Hawaii Medical Service Association Commercial	$20,371.30

Know your out-of-pocket cost for care.

All Charges