Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

sodium chloride 0.9% Irrig 2000 ml [HHSC]

Facility

$76.50

Service Code	NDC 00264738850
Hospital Charge Code	2500767
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$74.20
Rate for Payer: AlohaCare Medicaid	$38.25
Rate for Payer: AlohaCare Medicare	$38.25
Rate for Payer: Cash Price	$49.72
Rate for Payer: Devoted Health Medicare	$42.08
Rate for Payer: Hawaii Medical Service Association Medicare	$38.25
Rate for Payer: Hawaii Western Management Group Commercial	$72.67
Rate for Payer: Health Management Network Commercial	$65.03
Rate for Payer: Humana Medicare	$38.25
Rate for Payer: Kaiser Permanente Commercial	$68.85
Rate for Payer: Kaiser Permanente Medicaid	$39.02
Rate for Payer: Kaiser Permanente Medicare	$38.25
Rate for Payer: MDX Hawaii PPO	$74.20
Rate for Payer: Ohana Health Plan Medicaid	$38.25
Rate for Payer: Ohana Health Plan Medicare	$38.25
Rate for Payer: UnitedHealthcare Medicaid	$45.90
Rate for Payer: UnitedHealthcare Medicare	$38.25
Rate for Payer: University Health Alliance Commercial	$55.76

sodium chloride 0.9% Irrig 2000 ml [HHSC]

Facility

$76.50

Service Code	NDC 00264738850
Hospital Charge Code	2500767
Hospital Revenue Code	250
Min. Negotiated Rate	$65.03
Max. Negotiated Rate	$74.20
Rate for Payer: Cash Price	$49.72
Rate for Payer: Health Management Network Commercial	$65.03
Rate for Payer: Kaiser Permanente Commercial	$68.85
Rate for Payer: MDX Hawaii PPO	$74.20

sodium chloride 0.9% Irrig 2000 ml [HHSC]

Facility

$116.34

Service Code	NDC 00264220150
Hospital Charge Code	2500767
Hospital Revenue Code	250
Min. Negotiated Rate	$58.17
Max. Negotiated Rate	$112.85
Rate for Payer: AlohaCare Medicaid	$58.17
Rate for Payer: AlohaCare Medicare	$58.17
Rate for Payer: Cash Price	$75.62
Rate for Payer: Devoted Health Medicare	$63.99
Rate for Payer: Hawaii Medical Service Association Medicare	$58.17
Rate for Payer: Hawaii Western Management Group Commercial	$110.52
Rate for Payer: Health Management Network Commercial	$98.89
Rate for Payer: Humana Medicare	$58.17
Rate for Payer: Kaiser Permanente Commercial	$104.71
Rate for Payer: Kaiser Permanente Medicaid	$59.33
Rate for Payer: Kaiser Permanente Medicare	$58.17
Rate for Payer: MDX Hawaii PPO	$112.85
Rate for Payer: Ohana Health Plan Medicaid	$58.17
Rate for Payer: Ohana Health Plan Medicare	$58.17
Rate for Payer: UnitedHealthcare Medicaid	$69.80
Rate for Payer: UnitedHealthcare Medicare	$58.17
Rate for Payer: University Health Alliance Commercial	$84.80

sodium chloride 0.9% Irrig 2000 ml [HHSC]

Facility

$116.34

Service Code	NDC 00264220150
Hospital Charge Code	2500767
Hospital Revenue Code	250
Min. Negotiated Rate	$98.89
Max. Negotiated Rate	$112.85
Rate for Payer: Cash Price	$75.62
Rate for Payer: Health Management Network Commercial	$98.89
Rate for Payer: Kaiser Permanente Commercial	$104.71
Rate for Payer: MDX Hawaii PPO	$112.85

sodium chloride 0.9% irrig 3000 ml [HHSC]

Facility

$70.57

Service Code	NDC 00338004727
Hospital Charge Code	2500768
Hospital Revenue Code	250
Min. Negotiated Rate	$59.98
Max. Negotiated Rate	$68.45
Rate for Payer: Cash Price	$45.87
Rate for Payer: Health Management Network Commercial	$59.98
Rate for Payer: Kaiser Permanente Commercial	$63.51
Rate for Payer: MDX Hawaii PPO	$68.45

sodium chloride 0.9% irrig 3000 ml [HHSC]

Facility

$70.57

Service Code	NDC 00338004727
Hospital Charge Code	2500768
Hospital Revenue Code	272
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$68.45
Rate for Payer: AlohaCare Medicaid	$35.28
Rate for Payer: AlohaCare Medicare	$35.28
Rate for Payer: Cash Price	$45.87
Rate for Payer: Devoted Health Medicare	$38.81
Rate for Payer: Hawaii Medical Service Association Medicare	$35.28
Rate for Payer: Hawaii Western Management Group Commercial	$67.04
Rate for Payer: Health Management Network Commercial	$59.98
Rate for Payer: Humana Medicare	$35.28
Rate for Payer: Kaiser Permanente Commercial	$63.51
Rate for Payer: Kaiser Permanente Medicaid	$35.99
Rate for Payer: Kaiser Permanente Medicare	$35.28
Rate for Payer: MDX Hawaii PPO	$68.45
Rate for Payer: Ohana Health Plan Medicaid	$35.28
Rate for Payer: Ohana Health Plan Medicare	$35.28
Rate for Payer: UnitedHealthcare Medicare	$35.28
Rate for Payer: University Health Alliance Commercial	$51.44

sodium chloride 0.9% irrig 500 ml [HHSC]

Facility

$22.07

Service Code	NDC 00338004803
Hospital Charge Code	2500769
Hospital Revenue Code	250
Min. Negotiated Rate	$18.76
Max. Negotiated Rate	$21.41
Rate for Payer: Cash Price	$14.35
Rate for Payer: Health Management Network Commercial	$18.76
Rate for Payer: Kaiser Permanente Commercial	$19.86
Rate for Payer: MDX Hawaii PPO	$21.41

sodium chloride 0.9% irrig 500 ml [HHSC]

Facility

$22.07

Service Code	NDC 00338004803
Hospital Charge Code	2500769
Hospital Revenue Code	272
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$21.41
Rate for Payer: AlohaCare Medicaid	$11.04
Rate for Payer: AlohaCare Medicare	$11.04
Rate for Payer: Cash Price	$14.35
Rate for Payer: Devoted Health Medicare	$12.14
Rate for Payer: Hawaii Medical Service Association Medicare	$11.04
Rate for Payer: Hawaii Western Management Group Commercial	$20.97
Rate for Payer: Health Management Network Commercial	$18.76
Rate for Payer: Humana Medicare	$11.04
Rate for Payer: Kaiser Permanente Commercial	$19.86
Rate for Payer: Kaiser Permanente Medicaid	$11.26
Rate for Payer: Kaiser Permanente Medicare	$11.04
Rate for Payer: MDX Hawaii PPO	$21.41
Rate for Payer: Ohana Health Plan Medicaid	$11.04
Rate for Payer: Ohana Health Plan Medicare	$11.04
Rate for Payer: UnitedHealthcare Medicare	$11.04
Rate for Payer: University Health Alliance Commercial	$16.09

sodium chloride 0.9% irrig 500 ml [HHSC]

Facility

$9.34

Service Code	NDC 00264220110
Hospital Charge Code	2500769
Hospital Revenue Code	272
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$9.06
Rate for Payer: AlohaCare Medicaid	$4.67
Rate for Payer: AlohaCare Medicare	$4.67
Rate for Payer: Cash Price	$6.07
Rate for Payer: Devoted Health Medicare	$5.14
Rate for Payer: Hawaii Medical Service Association Medicare	$4.67
Rate for Payer: Hawaii Western Management Group Commercial	$8.87
Rate for Payer: Health Management Network Commercial	$7.94
Rate for Payer: Humana Medicare	$4.67
Rate for Payer: Kaiser Permanente Commercial	$8.41
Rate for Payer: Kaiser Permanente Medicaid	$4.76
Rate for Payer: Kaiser Permanente Medicare	$4.67
Rate for Payer: MDX Hawaii PPO	$9.06
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.67
Rate for Payer: UnitedHealthcare Medicare	$4.67
Rate for Payer: University Health Alliance Commercial	$6.81

sodium chloride 0.9% irrig 500 ml [HHSC]

Facility

$9.34

Service Code	NDC 00264220110
Hospital Charge Code	2500769
Hospital Revenue Code	250
Min. Negotiated Rate	$7.94
Max. Negotiated Rate	$9.06
Rate for Payer: Cash Price	$6.07
Rate for Payer: Health Management Network Commercial	$7.94
Rate for Payer: Kaiser Permanente Commercial	$8.41
Rate for Payer: MDX Hawaii PPO	$9.06

Sodium Chloride 0.9%- KCl 20 mEq 1000 mL [HHSC]

Facility

$14.79

Service Code	HCPCS J3480
Hospital Charge Code	2500774
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$14.35
Rate for Payer: AlohaCare Medicaid	$7.39
Rate for Payer: AlohaCare Medicaid	$29.28
Rate for Payer: AlohaCare Medicare	$29.28
Rate for Payer: AlohaCare Medicare	$7.39
Rate for Payer: Cash Price	$38.06
Rate for Payer: Cash Price	$9.61
Rate for Payer: Cash Price	$9.61
Rate for Payer: Cash Price	$38.06
Rate for Payer: Devoted Health Medicare	$8.13
Rate for Payer: Devoted Health Medicare	$32.21
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$29.28
Rate for Payer: Hawaii Medical Service Association Medicare	$7.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$14.05
Rate for Payer: Hawaii Western Management Group Commercial	$55.63
Rate for Payer: Health Management Network Commercial	$49.78
Rate for Payer: Health Management Network Commercial	$12.57
Rate for Payer: Humana Medicare	$7.39
Rate for Payer: Humana Medicare	$29.28
Rate for Payer: Kaiser Permanente Commercial	$13.31
Rate for Payer: Kaiser Permanente Commercial	$52.70
Rate for Payer: Kaiser Permanente Medicaid	$29.87
Rate for Payer: Kaiser Permanente Medicaid	$7.54
Rate for Payer: Kaiser Permanente Medicare	$7.39
Rate for Payer: Kaiser Permanente Medicare	$29.28
Rate for Payer: MDX Hawaii PPO	$14.35
Rate for Payer: MDX Hawaii PPO	$56.80
Rate for Payer: Ohana Health Plan Medicaid	$29.28
Rate for Payer: Ohana Health Plan Medicaid	$7.39
Rate for Payer: Ohana Health Plan Medicare	$7.39
Rate for Payer: Ohana Health Plan Medicare	$29.28
Rate for Payer: UnitedHealthcare Medicaid	$35.14
Rate for Payer: UnitedHealthcare Medicaid	$8.87
Rate for Payer: UnitedHealthcare Medicare	$7.39
Rate for Payer: UnitedHealthcare Medicare	$29.28
Rate for Payer: University Health Alliance Commercial	$10.78
Rate for Payer: University Health Alliance Commercial	$42.68

Sodium Chloride 0.9%- KCl 20 mEq 1000 mL [HHSC]

Facility

$14.79

Service Code	HCPCS J3480
Hospital Charge Code	2500774
Hospital Revenue Code	250
Min. Negotiated Rate	$12.57
Max. Negotiated Rate	$14.35
Rate for Payer: Cash Price	$9.61
Rate for Payer: Cash Price	$38.06
Rate for Payer: Health Management Network Commercial	$12.57
Rate for Payer: Health Management Network Commercial	$49.78
Rate for Payer: Kaiser Permanente Commercial	$13.31
Rate for Payer: Kaiser Permanente Commercial	$52.70
Rate for Payer: MDX Hawaii PPO	$56.80
Rate for Payer: MDX Hawaii PPO	$14.35

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 00223176001
Hospital Charge Code	2500777
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

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333084410
Hospital Charge Code	2500777
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

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333084410
Hospital Charge Code	2500777
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

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333083510
Hospital Charge Code	2500777
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

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 77333083510
Hospital Charge Code	2500777
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

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 69367022001
Hospital Charge Code	2500777
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

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 00223176001
Hospital Charge Code	2500777
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

sodium chloride 1 gm tablet [HHSC]

Facility

$3.00

Service Code	NDC 69367022001
Hospital Charge Code	2500777
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

sodium chloride 23.4% 100 mL vial [HHSC]

Facility

$95.45

Service Code	HCPCS J7131
Hospital Charge Code	2501184
Hospital Revenue Code	250
Min. Negotiated Rate	$81.13
Max. Negotiated Rate	$92.59
Rate for Payer: Cash Price	$62.04
Rate for Payer: Health Management Network Commercial	$81.13
Rate for Payer: Kaiser Permanente Commercial	$85.91
Rate for Payer: MDX Hawaii PPO	$92.59

sodium chloride 23.4% 100 mL vial [HHSC]

Facility

$95.45

Service Code	HCPCS J7131
Hospital Charge Code	2501184
Hospital Revenue Code	636
Min. Negotiated Rate	$47.73
Max. Negotiated Rate	$92.59
Rate for Payer: AlohaCare Medicaid	$47.73
Rate for Payer: AlohaCare Medicare	$47.73
Rate for Payer: Cash Price	$62.04
Rate for Payer: Devoted Health Medicare	$52.50
Rate for Payer: Hawaii Medical Service Association Medicare	$47.73
Rate for Payer: Hawaii Western Management Group Commercial	$90.68
Rate for Payer: Health Management Network Commercial	$81.13
Rate for Payer: Humana Medicare	$47.73
Rate for Payer: Kaiser Permanente Commercial	$85.91
Rate for Payer: Kaiser Permanente Medicaid	$48.68
Rate for Payer: Kaiser Permanente Medicare	$47.73
Rate for Payer: MDX Hawaii PPO	$92.59
Rate for Payer: Ohana Health Plan Medicaid	$47.73
Rate for Payer: Ohana Health Plan Medicare	$47.73
Rate for Payer: UnitedHealthcare Medicaid	$57.27
Rate for Payer: UnitedHealthcare Medicare	$47.73
Rate for Payer: University Health Alliance Commercial	$69.57

sodium chloride 23.4% 30 mL vial [HHSC]

Facility

$43.81

Service Code	HCPCS J7131
Hospital Charge Code	2500778
Hospital Revenue Code	636
Min. Negotiated Rate	$21.91
Max. Negotiated Rate	$42.50
Rate for Payer: AlohaCare Medicaid	$21.91
Rate for Payer: AlohaCare Medicaid	$14.98
Rate for Payer: AlohaCare Medicare	$21.91
Rate for Payer: AlohaCare Medicare	$14.98
Rate for Payer: Cash Price	$19.47
Rate for Payer: Cash Price	$28.48
Rate for Payer: Devoted Health Medicare	$16.48
Rate for Payer: Devoted Health Medicare	$24.10
Rate for Payer: Hawaii Medical Service Association Medicare	$14.98
Rate for Payer: Hawaii Medical Service Association Medicare	$21.91
Rate for Payer: Hawaii Western Management Group Commercial	$41.62
Rate for Payer: Hawaii Western Management Group Commercial	$28.46
Rate for Payer: Health Management Network Commercial	$37.24
Rate for Payer: Health Management Network Commercial	$25.47
Rate for Payer: Humana Medicare	$14.98
Rate for Payer: Humana Medicare	$21.91
Rate for Payer: Kaiser Permanente Commercial	$26.96
Rate for Payer: Kaiser Permanente Commercial	$39.43
Rate for Payer: Kaiser Permanente Medicaid	$15.28
Rate for Payer: Kaiser Permanente Medicaid	$22.34
Rate for Payer: Kaiser Permanente Medicare	$21.91
Rate for Payer: Kaiser Permanente Medicare	$14.98
Rate for Payer: MDX Hawaii PPO	$42.50
Rate for Payer: MDX Hawaii PPO	$29.06
Rate for Payer: Ohana Health Plan Medicaid	$21.91
Rate for Payer: Ohana Health Plan Medicaid	$14.98
Rate for Payer: Ohana Health Plan Medicare	$14.98
Rate for Payer: Ohana Health Plan Medicare	$21.91
Rate for Payer: UnitedHealthcare Medicaid	$26.29
Rate for Payer: UnitedHealthcare Medicaid	$17.98
Rate for Payer: UnitedHealthcare Medicare	$14.98
Rate for Payer: UnitedHealthcare Medicare	$21.91
Rate for Payer: University Health Alliance Commercial	$21.84
Rate for Payer: University Health Alliance Commercial	$31.93

sodium chloride 23.4% 30 mL vial [HHSC]

Facility

$43.81

Service Code	HCPCS J7131
Hospital Charge Code	2500778
Hospital Revenue Code	250
Min. Negotiated Rate	$37.24
Max. Negotiated Rate	$42.50
Rate for Payer: Cash Price	$28.48
Rate for Payer: Cash Price	$19.47
Rate for Payer: Health Management Network Commercial	$25.47
Rate for Payer: Health Management Network Commercial	$37.24
Rate for Payer: Kaiser Permanente Commercial	$26.96
Rate for Payer: Kaiser Permanente Commercial	$39.43
Rate for Payer: MDX Hawaii PPO	$42.50
Rate for Payer: MDX Hawaii PPO	$29.06

sodium chloride 3% 4 mL neb soln [HHSC]

Facility

$4.67

Service Code	NDC 76204002260
Hospital Charge Code	2500779
Hospital Revenue Code	250
Min. Negotiated Rate	$2.33
Max. Negotiated Rate	$4.53
Rate for Payer: AlohaCare Medicaid	$2.33
Rate for Payer: AlohaCare Medicare	$2.33
Rate for Payer: Cash Price	$3.04
Rate for Payer: Devoted Health Medicare	$2.57
Rate for Payer: Hawaii Medical Service Association Medicare	$2.33
Rate for Payer: Hawaii Western Management Group Commercial	$4.44
Rate for Payer: Health Management Network Commercial	$3.97
Rate for Payer: Humana Medicare	$2.33
Rate for Payer: Kaiser Permanente Commercial	$4.20
Rate for Payer: Kaiser Permanente Medicaid	$2.38
Rate for Payer: Kaiser Permanente Medicare	$2.33
Rate for Payer: MDX Hawaii PPO	$4.53
Rate for Payer: Ohana Health Plan Medicaid	$2.33
Rate for Payer: Ohana Health Plan Medicare	$2.33
Rate for Payer: UnitedHealthcare Medicaid	$2.80
Rate for Payer: UnitedHealthcare Medicare	$2.33
Rate for Payer: University Health Alliance Commercial	$3.40

Know your out-of-pocket cost for care.

All Charges