Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

temazepam 15 mg capsule [HHSC]

Facility

$5.44

Service Code	NDC 50268077915
Hospital Charge Code	2500807
Hospital Revenue Code	250
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$5.28
Rate for Payer: Cash Price	$3.54
Rate for Payer: Health Management Network Commercial	$4.62
Rate for Payer: Kaiser Permanente Commercial	$4.90
Rate for Payer: MDX Hawaii PPO	$5.28

temazepam 15 mg capsule [HHSC]

Facility

$4.08

Service Code	NDC 00228207610
Hospital Charge Code	2500807
Hospital Revenue Code	250
Min. Negotiated Rate	$3.47
Max. Negotiated Rate	$3.96
Rate for Payer: Cash Price	$2.65
Rate for Payer: Health Management Network Commercial	$3.47
Rate for Payer: Kaiser Permanente Commercial	$3.67
Rate for Payer: MDX Hawaii PPO	$3.96

temazepam 15 mg capsule [HHSC]

Facility

$4.08

Service Code	NDC 00228207610
Hospital Charge Code	2500807
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.96
Rate for Payer: AlohaCare Medicaid	$2.04
Rate for Payer: AlohaCare Medicare	$2.04
Rate for Payer: Cash Price	$2.65
Rate for Payer: Devoted Health Medicare	$2.24
Rate for Payer: Hawaii Medical Service Association Medicare	$2.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.88
Rate for Payer: Health Management Network Commercial	$3.47
Rate for Payer: Humana Medicare	$2.04
Rate for Payer: Kaiser Permanente Commercial	$3.67
Rate for Payer: Kaiser Permanente Medicaid	$2.08
Rate for Payer: Kaiser Permanente Medicare	$2.04
Rate for Payer: MDX Hawaii PPO	$3.96
Rate for Payer: Ohana Health Plan Medicaid	$2.04
Rate for Payer: Ohana Health Plan Medicare	$2.04
Rate for Payer: UnitedHealthcare Medicaid	$2.45
Rate for Payer: UnitedHealthcare Medicare	$2.04
Rate for Payer: University Health Alliance Commercial	$2.97

TENDONITIS, MYOSITIS AND BURSITIS WITH MCC

Facility

$21,263.66

Service Code	MSDRG 557
Min. Negotiated Rate	$21,263.66
Max. Negotiated Rate	$21,263.66
Rate for Payer: Hawaii Medical Service Association Commercial	$21,263.66

TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC

Facility

$21,263.66

Service Code	MSDRG 558
Min. Negotiated Rate	$21,263.66
Max. Negotiated Rate	$21,263.66
Rate for Payer: Hawaii Medical Service Association Commercial	$21,263.66

TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)

Facility

$5,655.00

Service Code	CPT 26055
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: University Health Alliance Commercial	$5,160.40

tenecteplase 50 mg kit [HHSC]

Facility

$12,162.35

Service Code	HCPCS J3101
Hospital Charge Code	2500808
Hospital Revenue Code	250
Min. Negotiated Rate	$10,338.00
Max. Negotiated Rate	$11,797.48
Rate for Payer: Cash Price	$7,905.53
Rate for Payer: Cash Price	$8,563.97
Rate for Payer: Health Management Network Commercial	$10,338.00
Rate for Payer: Health Management Network Commercial	$11,199.04
Rate for Payer: Kaiser Permanente Commercial	$11,857.81
Rate for Payer: Kaiser Permanente Commercial	$10,946.11
Rate for Payer: MDX Hawaii PPO	$11,797.48
Rate for Payer: MDX Hawaii PPO	$12,780.08

tenecteplase 50 mg kit [HHSC]

Facility

$13,175.34

Service Code	HCPCS J3101
Hospital Charge Code	2500808
Hospital Revenue Code	636
Min. Negotiated Rate	$171.94
Max. Negotiated Rate	$12,780.08
Rate for Payer: AlohaCare Medicaid	$6,587.67
Rate for Payer: AlohaCare Medicaid	$6,081.18
Rate for Payer: AlohaCare Medicare	$6,587.67
Rate for Payer: AlohaCare Medicare	$6,081.18
Rate for Payer: Cash Price	$7,905.53
Rate for Payer: Cash Price	$7,905.53
Rate for Payer: Cash Price	$8,563.97
Rate for Payer: Cash Price	$8,563.97
Rate for Payer: Devoted Health Medicare	$7,246.44
Rate for Payer: Devoted Health Medicare	$6,689.29
Rate for Payer: Hawaii Medical Service Association ABD	$171.94
Rate for Payer: Hawaii Medical Service Association ABD	$171.94
Rate for Payer: Hawaii Medical Service Association Commercial	$246.80
Rate for Payer: Hawaii Medical Service Association Commercial	$246.80
Rate for Payer: Hawaii Medical Service Association Medicare	$6,587.67
Rate for Payer: Hawaii Medical Service Association Medicare	$6,081.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$171.94
Rate for Payer: Hawaii Medical Service Association Non-ABD	$171.94
Rate for Payer: Hawaii Western Management Group Commercial	$12,516.57
Rate for Payer: Hawaii Western Management Group Commercial	$11,554.23
Rate for Payer: Health Management Network Commercial	$11,199.04
Rate for Payer: Health Management Network Commercial	$10,338.00
Rate for Payer: Humana Medicare	$6,081.18
Rate for Payer: Humana Medicare	$6,587.67
Rate for Payer: Kaiser Permanente Commercial	$11,857.81
Rate for Payer: Kaiser Permanente Commercial	$10,946.11
Rate for Payer: Kaiser Permanente Medicaid	$6,202.80
Rate for Payer: Kaiser Permanente Medicaid	$6,719.42
Rate for Payer: Kaiser Permanente Medicare	$6,587.67
Rate for Payer: Kaiser Permanente Medicare	$6,081.18
Rate for Payer: MDX Hawaii PPO	$12,780.08
Rate for Payer: MDX Hawaii PPO	$11,797.48
Rate for Payer: Ohana Health Plan Medicaid	$6,081.18
Rate for Payer: Ohana Health Plan Medicaid	$6,587.67
Rate for Payer: Ohana Health Plan Medicare	$6,081.18
Rate for Payer: Ohana Health Plan Medicare	$6,587.67
Rate for Payer: UnitedHealthcare Medicaid	$7,297.41
Rate for Payer: UnitedHealthcare Medicaid	$7,905.20
Rate for Payer: UnitedHealthcare Medicare	$6,081.18
Rate for Payer: UnitedHealthcare Medicare	$6,587.67
Rate for Payer: University Health Alliance Commercial	$9,603.51
Rate for Payer: University Health Alliance Commercial	$8,865.14

TENMO EVOLUTION 14GX11CM (CT)

Facility

$220.00

Hospital Charge Code	9800830
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 14GX11CM (CT)

Facility

$220.00

Hospital Charge Code	9800830
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800835
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 14GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800835
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX6CM (CT)

Facility

$220.00

Hospital Charge Code	9800829
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 14GX6CM (CT)

Facility

$220.00

Hospital Charge Code	9800829
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX6CM (US)

Facility

$220.00

Hospital Charge Code	9800834
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX6CM (US)

Facility

$220.00

Hospital Charge Code	9800834
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 14GX6CM (XR)

Facility

$220.00

Hospital Charge Code	9800799
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 14GX6CM (XR)

Facility

$220.00

Hospital Charge Code	9800799
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX11CM (CT)

Facility

$220.00

Hospital Charge Code	9800827
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX11CM (CT)

Facility

$220.00

Hospital Charge Code	9800827
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800832
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX11CM (US)

Facility

$220.00

Hospital Charge Code	9800832
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX11CM (XR)

Facility

$220.00

Hospital Charge Code	9800797
Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$143.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: MDX Hawaii PPO	$213.40

TENMO EVOLUTION 16GX11CM (XR)

Facility

$220.00

Hospital Charge Code	9800797
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

TENMO EVOLUTION 16GX15CM (US)

Facility

$220.00

Hospital Charge Code	9800833
Hospital Revenue Code	272
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$213.40
Rate for Payer: AlohaCare Medicaid	$110.00
Rate for Payer: AlohaCare Medicare	$110.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Medicare	$110.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Humana Medicare	$110.00
Rate for Payer: Kaiser Permanente Commercial	$198.00
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: Kaiser Permanente Medicare	$110.00
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: Ohana Health Plan Medicaid	$110.00
Rate for Payer: Ohana Health Plan Medicare	$110.00
Rate for Payer: UnitedHealthcare Medicare	$110.00
Rate for Payer: University Health Alliance Commercial	$160.36

Know your out-of-pocket cost for care.

All Charges