Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

SLP Video Swallow

Facility

$581.00

Service Code	HCPCS 92611 GP,CQ
Hospital Charge Code	675810
Hospital Revenue Code	444
Min. Negotiated Rate	$493.85
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$377.65
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: MDX Hawaii PPO	$563.57

sodium acetate 40 mEq/20 ml vial [HHSC]

Facility

$12.74

Service Code	NDC 00409729973
Hospital Charge Code	2500752
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$12.36
Rate for Payer: AlohaCare Medicaid	$6.37
Rate for Payer: AlohaCare Medicare	$6.37
Rate for Payer: Cash Price	$8.28
Rate for Payer: Devoted Health Medicare	$7.01
Rate for Payer: Hawaii Medical Service Association Medicare	$6.37
Rate for Payer: Hawaii Western Management Group Commercial	$12.10
Rate for Payer: Health Management Network Commercial	$10.83
Rate for Payer: Humana Medicare	$6.37
Rate for Payer: Kaiser Permanente Commercial	$11.47
Rate for Payer: Kaiser Permanente Medicaid	$6.50
Rate for Payer: Kaiser Permanente Medicare	$6.37
Rate for Payer: MDX Hawaii PPO	$12.36
Rate for Payer: Ohana Health Plan Medicaid	$6.37
Rate for Payer: Ohana Health Plan Medicare	$6.37
Rate for Payer: UnitedHealthcare Medicaid	$7.64
Rate for Payer: UnitedHealthcare Medicare	$6.37
Rate for Payer: University Health Alliance Commercial	$9.29

sodium acetate 40 mEq/20 ml vial [HHSC]

Facility

$12.74

Service Code	NDC 00409729973
Hospital Charge Code	2500752
Hospital Revenue Code	250
Min. Negotiated Rate	$10.83
Max. Negotiated Rate	$12.36
Rate for Payer: Cash Price	$8.28
Rate for Payer: Health Management Network Commercial	$10.83
Rate for Payer: Kaiser Permanente Commercial	$11.47
Rate for Payer: MDX Hawaii PPO	$12.36

sodium acetate 40 mEq/20 ml vial [HHSC]

Facility

$19.62

Service Code	NDC 00409729925
Hospital Charge Code	2500752
Hospital Revenue Code	250
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$19.03
Rate for Payer: AlohaCare Medicaid	$9.81
Rate for Payer: AlohaCare Medicare	$9.81
Rate for Payer: Cash Price	$12.75
Rate for Payer: Devoted Health Medicare	$10.79
Rate for Payer: Hawaii Medical Service Association Medicare	$9.81
Rate for Payer: Hawaii Western Management Group Commercial	$18.64
Rate for Payer: Health Management Network Commercial	$16.68
Rate for Payer: Humana Medicare	$9.81
Rate for Payer: Kaiser Permanente Commercial	$17.66
Rate for Payer: Kaiser Permanente Medicaid	$10.01
Rate for Payer: Kaiser Permanente Medicare	$9.81
Rate for Payer: MDX Hawaii PPO	$19.03
Rate for Payer: Ohana Health Plan Medicaid	$9.81
Rate for Payer: Ohana Health Plan Medicare	$9.81
Rate for Payer: UnitedHealthcare Medicaid	$11.77
Rate for Payer: UnitedHealthcare Medicare	$9.81
Rate for Payer: University Health Alliance Commercial	$14.30

sodium acetate 40 mEq/20 ml vial [HHSC]

Facility

$19.62

Service Code	NDC 00409729925
Hospital Charge Code	2500752
Hospital Revenue Code	250
Min. Negotiated Rate	$16.68
Max. Negotiated Rate	$19.03
Rate for Payer: Cash Price	$12.75
Rate for Payer: Health Management Network Commercial	$16.68
Rate for Payer: Kaiser Permanente Commercial	$17.66
Rate for Payer: MDX Hawaii PPO	$19.03

Sodium (Arterial) POCT

Facility

$225.00

Service Code	HCPCS 84295
Hospital Charge Code	9364699
Hospital Revenue Code	301
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$112.50
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Devoted Health Medicare	$123.75
Rate for Payer: Hawaii Medical Service Association ABD	$6.65
Rate for Payer: Hawaii Medical Service Association Commercial	$6.01
Rate for Payer: Hawaii Medical Service Association Medicare	$112.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.98
Rate for Payer: Hawaii Western Management Group Commercial	$4.81
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$112.50
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$112.50
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$112.50
Rate for Payer: Ohana Health Plan Medicare	$112.50
Rate for Payer: UnitedHealthcare Medicaid	$6.65
Rate for Payer: UnitedHealthcare Medicare	$112.50
Rate for Payer: University Health Alliance Commercial	$12.43

Sodium (Arterial) POCT

Facility

$225.00

Service Code	HCPCS 84295
Hospital Charge Code	9364699
Hospital Revenue Code	301
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

sodium bicarbonate 2.5mEq/ 5 ml vial [HHSC]

Facility

$54.27

Service Code	NDC 00409555502
Hospital Charge Code	2501005
Hospital Revenue Code	250
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$52.64
Rate for Payer: AlohaCare Medicaid	$27.14
Rate for Payer: AlohaCare Medicare	$27.14
Rate for Payer: Cash Price	$35.28
Rate for Payer: Devoted Health Medicare	$29.85
Rate for Payer: Hawaii Medical Service Association Medicare	$27.14
Rate for Payer: Hawaii Western Management Group Commercial	$51.56
Rate for Payer: Health Management Network Commercial	$46.13
Rate for Payer: Humana Medicare	$27.14
Rate for Payer: Kaiser Permanente Commercial	$48.84
Rate for Payer: Kaiser Permanente Medicaid	$27.68
Rate for Payer: Kaiser Permanente Medicare	$27.14
Rate for Payer: MDX Hawaii PPO	$52.64
Rate for Payer: Ohana Health Plan Medicaid	$27.14
Rate for Payer: Ohana Health Plan Medicare	$27.14
Rate for Payer: UnitedHealthcare Medicaid	$32.56
Rate for Payer: UnitedHealthcare Medicare	$27.14
Rate for Payer: University Health Alliance Commercial	$39.56

sodium bicarbonate 2.5mEq/ 5 ml vial [HHSC]

Facility

$121.68

Service Code	NDC 63323008305
Hospital Charge Code	2501005
Hospital Revenue Code	250
Min. Negotiated Rate	$60.84
Max. Negotiated Rate	$118.03
Rate for Payer: AlohaCare Medicaid	$60.84
Rate for Payer: AlohaCare Medicare	$60.84
Rate for Payer: Cash Price	$79.09
Rate for Payer: Devoted Health Medicare	$66.92
Rate for Payer: Hawaii Medical Service Association Medicare	$60.84
Rate for Payer: Hawaii Western Management Group Commercial	$115.60
Rate for Payer: Health Management Network Commercial	$103.43
Rate for Payer: Humana Medicare	$60.84
Rate for Payer: Kaiser Permanente Commercial	$109.51
Rate for Payer: Kaiser Permanente Medicaid	$62.06
Rate for Payer: Kaiser Permanente Medicare	$60.84
Rate for Payer: MDX Hawaii PPO	$118.03
Rate for Payer: Ohana Health Plan Medicaid	$60.84
Rate for Payer: Ohana Health Plan Medicare	$60.84
Rate for Payer: UnitedHealthcare Medicaid	$73.01
Rate for Payer: UnitedHealthcare Medicare	$60.84
Rate for Payer: University Health Alliance Commercial	$88.69

sodium bicarbonate 2.5mEq/ 5 ml vial [HHSC]

Facility

$121.68

Service Code	NDC 63323008305
Hospital Charge Code	2501005
Hospital Revenue Code	250
Min. Negotiated Rate	$103.43
Max. Negotiated Rate	$118.03
Rate for Payer: Cash Price	$79.09
Rate for Payer: Health Management Network Commercial	$103.43
Rate for Payer: Kaiser Permanente Commercial	$109.51
Rate for Payer: MDX Hawaii PPO	$118.03

sodium bicarbonate 2.5mEq/ 5 ml vial [HHSC]

Facility

$54.27

Service Code	NDC 00409555501
Hospital Charge Code	2501005
Hospital Revenue Code	250
Min. Negotiated Rate	$27.14
Max. Negotiated Rate	$52.64
Rate for Payer: AlohaCare Medicaid	$27.14
Rate for Payer: AlohaCare Medicare	$27.14
Rate for Payer: Cash Price	$35.28
Rate for Payer: Devoted Health Medicare	$29.85
Rate for Payer: Hawaii Medical Service Association Medicare	$27.14
Rate for Payer: Hawaii Western Management Group Commercial	$51.56
Rate for Payer: Health Management Network Commercial	$46.13
Rate for Payer: Humana Medicare	$27.14
Rate for Payer: Kaiser Permanente Commercial	$48.84
Rate for Payer: Kaiser Permanente Medicaid	$27.68
Rate for Payer: Kaiser Permanente Medicare	$27.14
Rate for Payer: MDX Hawaii PPO	$52.64
Rate for Payer: Ohana Health Plan Medicaid	$27.14
Rate for Payer: Ohana Health Plan Medicare	$27.14
Rate for Payer: UnitedHealthcare Medicaid	$32.56
Rate for Payer: UnitedHealthcare Medicare	$27.14
Rate for Payer: University Health Alliance Commercial	$39.56

sodium bicarbonate 2.5mEq/ 5 ml vial [HHSC]

Facility

$54.27

Service Code	NDC 00409555501
Hospital Charge Code	2501005
Hospital Revenue Code	250
Min. Negotiated Rate	$46.13
Max. Negotiated Rate	$52.64
Rate for Payer: Cash Price	$35.28
Rate for Payer: Health Management Network Commercial	$46.13
Rate for Payer: Kaiser Permanente Commercial	$48.84
Rate for Payer: MDX Hawaii PPO	$52.64

sodium bicarbonate 2.5mEq/ 5 ml vial [HHSC]

Facility

$54.27

Service Code	NDC 00409555502
Hospital Charge Code	2501005
Hospital Revenue Code	250
Min. Negotiated Rate	$46.13
Max. Negotiated Rate	$52.64
Rate for Payer: Cash Price	$35.28
Rate for Payer: Health Management Network Commercial	$46.13
Rate for Payer: Kaiser Permanente Commercial	$48.84
Rate for Payer: MDX Hawaii PPO	$52.64

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$71.12

Service Code	NDC 00409663734
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$60.45
Max. Negotiated Rate	$68.99
Rate for Payer: Cash Price	$46.23
Rate for Payer: Health Management Network Commercial	$60.45
Rate for Payer: Kaiser Permanente Commercial	$64.01
Rate for Payer: MDX Hawaii PPO	$68.99

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$67.49

Service Code	NDC 00409662514
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$33.74
Max. Negotiated Rate	$65.47
Rate for Payer: AlohaCare Medicaid	$33.74
Rate for Payer: AlohaCare Medicare	$33.74
Rate for Payer: Cash Price	$43.87
Rate for Payer: Devoted Health Medicare	$37.12
Rate for Payer: Hawaii Medical Service Association Medicare	$33.74
Rate for Payer: Hawaii Western Management Group Commercial	$64.12
Rate for Payer: Health Management Network Commercial	$57.37
Rate for Payer: Humana Medicare	$33.74
Rate for Payer: Kaiser Permanente Commercial	$60.74
Rate for Payer: Kaiser Permanente Medicaid	$34.42
Rate for Payer: Kaiser Permanente Medicare	$33.74
Rate for Payer: MDX Hawaii PPO	$65.47
Rate for Payer: Ohana Health Plan Medicaid	$33.74
Rate for Payer: Ohana Health Plan Medicare	$33.74
Rate for Payer: UnitedHealthcare Medicaid	$40.49
Rate for Payer: UnitedHealthcare Medicare	$33.74
Rate for Payer: University Health Alliance Commercial	$49.19

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$72.46

Service Code	NDC 00409663714
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$61.59
Max. Negotiated Rate	$70.29
Rate for Payer: Cash Price	$47.10
Rate for Payer: Health Management Network Commercial	$61.59
Rate for Payer: Kaiser Permanente Commercial	$65.21
Rate for Payer: MDX Hawaii PPO	$70.29

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$68.31

Service Code	NDC 76329335201
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$34.16
Max. Negotiated Rate	$66.26
Rate for Payer: AlohaCare Medicaid	$34.16
Rate for Payer: AlohaCare Medicare	$34.16
Rate for Payer: Cash Price	$44.40
Rate for Payer: Devoted Health Medicare	$37.57
Rate for Payer: Hawaii Medical Service Association Medicare	$34.16
Rate for Payer: Hawaii Western Management Group Commercial	$64.89
Rate for Payer: Health Management Network Commercial	$58.06
Rate for Payer: Humana Medicare	$34.16
Rate for Payer: Kaiser Permanente Commercial	$61.48
Rate for Payer: Kaiser Permanente Medicaid	$34.84
Rate for Payer: Kaiser Permanente Medicare	$34.16
Rate for Payer: MDX Hawaii PPO	$66.26
Rate for Payer: Ohana Health Plan Medicaid	$34.16
Rate for Payer: Ohana Health Plan Medicare	$34.16
Rate for Payer: UnitedHealthcare Medicaid	$40.99
Rate for Payer: UnitedHealthcare Medicare	$34.16
Rate for Payer: University Health Alliance Commercial	$49.79

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$61.03

Service Code	NDC 00409662525
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$51.88
Max. Negotiated Rate	$59.20
Rate for Payer: Cash Price	$39.67
Rate for Payer: Health Management Network Commercial	$51.88
Rate for Payer: Kaiser Permanente Commercial	$54.93
Rate for Payer: MDX Hawaii PPO	$59.20

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$117.97

Service Code	NDC 63323008950
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$100.27
Max. Negotiated Rate	$114.43
Rate for Payer: Cash Price	$76.68
Rate for Payer: Health Management Network Commercial	$100.27
Rate for Payer: Kaiser Permanente Commercial	$106.17
Rate for Payer: MDX Hawaii PPO	$114.43

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$60.82

Service Code	NDC 51754500105
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$30.41
Max. Negotiated Rate	$59.00
Rate for Payer: AlohaCare Medicaid	$30.41
Rate for Payer: AlohaCare Medicare	$30.41
Rate for Payer: Cash Price	$39.53
Rate for Payer: Devoted Health Medicare	$33.45
Rate for Payer: Hawaii Medical Service Association Medicare	$30.41
Rate for Payer: Hawaii Western Management Group Commercial	$57.78
Rate for Payer: Health Management Network Commercial	$51.70
Rate for Payer: Humana Medicare	$30.41
Rate for Payer: Kaiser Permanente Commercial	$54.74
Rate for Payer: Kaiser Permanente Medicaid	$31.02
Rate for Payer: Kaiser Permanente Medicare	$30.41
Rate for Payer: MDX Hawaii PPO	$59.00
Rate for Payer: Ohana Health Plan Medicaid	$30.41
Rate for Payer: Ohana Health Plan Medicare	$30.41
Rate for Payer: UnitedHealthcare Medicaid	$36.49
Rate for Payer: UnitedHealthcare Medicare	$30.41
Rate for Payer: University Health Alliance Commercial	$44.33

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$64.77

Service Code	NDC 00409662502
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$55.05
Max. Negotiated Rate	$62.83
Rate for Payer: Cash Price	$42.10
Rate for Payer: Health Management Network Commercial	$55.05
Rate for Payer: Kaiser Permanente Commercial	$58.29
Rate for Payer: MDX Hawaii PPO	$62.83

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$61.03

Service Code	NDC 00409662525
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$30.52
Max. Negotiated Rate	$59.20
Rate for Payer: AlohaCare Medicaid	$30.52
Rate for Payer: AlohaCare Medicare	$30.52
Rate for Payer: Cash Price	$39.67
Rate for Payer: Devoted Health Medicare	$33.57
Rate for Payer: Hawaii Medical Service Association Medicare	$30.52
Rate for Payer: Hawaii Western Management Group Commercial	$57.98
Rate for Payer: Health Management Network Commercial	$51.88
Rate for Payer: Humana Medicare	$30.52
Rate for Payer: Kaiser Permanente Commercial	$54.93
Rate for Payer: Kaiser Permanente Medicaid	$31.13
Rate for Payer: Kaiser Permanente Medicare	$30.52
Rate for Payer: MDX Hawaii PPO	$59.20
Rate for Payer: Ohana Health Plan Medicaid	$30.52
Rate for Payer: Ohana Health Plan Medicare	$30.52
Rate for Payer: UnitedHealthcare Medicaid	$36.62
Rate for Payer: UnitedHealthcare Medicare	$30.52
Rate for Payer: University Health Alliance Commercial	$44.48

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$72.46

Service Code	NDC 00409663714
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$36.23
Max. Negotiated Rate	$70.29
Rate for Payer: AlohaCare Medicaid	$36.23
Rate for Payer: AlohaCare Medicare	$36.23
Rate for Payer: Cash Price	$47.10
Rate for Payer: Devoted Health Medicare	$39.85
Rate for Payer: Hawaii Medical Service Association Medicare	$36.23
Rate for Payer: Hawaii Western Management Group Commercial	$68.84
Rate for Payer: Health Management Network Commercial	$61.59
Rate for Payer: Humana Medicare	$36.23
Rate for Payer: Kaiser Permanente Commercial	$65.21
Rate for Payer: Kaiser Permanente Medicaid	$36.95
Rate for Payer: Kaiser Permanente Medicare	$36.23
Rate for Payer: MDX Hawaii PPO	$70.29
Rate for Payer: Ohana Health Plan Medicaid	$36.23
Rate for Payer: Ohana Health Plan Medicare	$36.23
Rate for Payer: UnitedHealthcare Medicaid	$43.48
Rate for Payer: UnitedHealthcare Medicare	$36.23
Rate for Payer: University Health Alliance Commercial	$52.82

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$117.97

Service Code	NDC 63323008950
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$58.98
Max. Negotiated Rate	$114.43
Rate for Payer: AlohaCare Medicaid	$58.98
Rate for Payer: AlohaCare Medicare	$58.98
Rate for Payer: Cash Price	$76.68
Rate for Payer: Devoted Health Medicare	$64.88
Rate for Payer: Hawaii Medical Service Association Medicare	$58.98
Rate for Payer: Hawaii Western Management Group Commercial	$112.07
Rate for Payer: Health Management Network Commercial	$100.27
Rate for Payer: Humana Medicare	$58.98
Rate for Payer: Kaiser Permanente Commercial	$106.17
Rate for Payer: Kaiser Permanente Medicaid	$60.16
Rate for Payer: Kaiser Permanente Medicare	$58.98
Rate for Payer: MDX Hawaii PPO	$114.43
Rate for Payer: Ohana Health Plan Medicaid	$58.98
Rate for Payer: Ohana Health Plan Medicare	$58.98
Rate for Payer: UnitedHealthcare Medicaid	$70.78
Rate for Payer: UnitedHealthcare Medicare	$58.98
Rate for Payer: University Health Alliance Commercial	$85.99

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$68.31

Service Code	NDC 76329335201
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$58.06
Max. Negotiated Rate	$66.26
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$58.06
Rate for Payer: Kaiser Permanente Commercial	$61.48
Rate for Payer: MDX Hawaii PPO	$66.26

Know your out-of-pocket cost for care.

All Charges