Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

TENMO EVOLUTION 20GX15CM (XR/MAMMO)

Facility

$220.00

Hospital Charge Code	9023978
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 20GX15CM (XR/MAMMO)

Facility

$220.00

Hospital Charge Code	9023978
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 20G X 6CM (CT)

Facility

$321.00

Hospital Charge Code	9023976
Hospital Revenue Code	272
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

TENMO EVOLUTION 20G X 6CM (CT)

Facility

$321.00

Hospital Charge Code	9023976
Hospital Revenue Code	272
Min. Negotiated Rate	$160.50
Max. Negotiated Rate	$311.37
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Western Management Group Commercial	$304.95
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$233.98

TENMO EVOLUTION 20G X 6CM (US)

Facility

$321.00

Hospital Charge Code	9023977
Hospital Revenue Code	272
Min. Negotiated Rate	$160.50
Max. Negotiated Rate	$311.37
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Western Management Group Commercial	$304.95
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$233.98

TENMO EVOLUTION 20G X 6CM (US)

Facility

$321.00

Hospital Charge Code	9023977
Hospital Revenue Code	272
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

TENMO EVOLUTION 20G X 6CM (XR/MAMMO)

Facility

$321.00

Hospital Charge Code	9023975
Hospital Revenue Code	272
Min. Negotiated Rate	$160.50
Max. Negotiated Rate	$311.37
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Western Management Group Commercial	$304.95
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$233.98

TENMO EVOLUTION 20G X 6CM (XR/MAMMO)

Facility

$321.00

Hospital Charge Code	9023975
Hospital Revenue Code	272
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

terazosin 1 mg capsule [HHSC]

Facility

$8.93

Service Code	NDC 50268076415
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$8.66
Rate for Payer: Cash Price	$5.80
Rate for Payer: Health Management Network Commercial	$7.59
Rate for Payer: Kaiser Permanente Commercial	$8.04
Rate for Payer: MDX Hawaii PPO	$8.66

terazosin 1 mg capsule [HHSC]

Facility

$8.03

Service Code	NDC 00904612661
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$7.79
Rate for Payer: AlohaCare Medicaid	$4.01
Rate for Payer: AlohaCare Medicare	$4.01
Rate for Payer: Cash Price	$5.22
Rate for Payer: Devoted Health Medicare	$4.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.01
Rate for Payer: Hawaii Western Management Group Commercial	$7.63
Rate for Payer: Health Management Network Commercial	$6.83
Rate for Payer: Humana Medicare	$4.01
Rate for Payer: Kaiser Permanente Commercial	$7.23
Rate for Payer: Kaiser Permanente Medicaid	$4.10
Rate for Payer: Kaiser Permanente Medicare	$4.01
Rate for Payer: MDX Hawaii PPO	$7.79
Rate for Payer: Ohana Health Plan Medicaid	$4.01
Rate for Payer: Ohana Health Plan Medicare	$4.01
Rate for Payer: UnitedHealthcare Medicaid	$4.82
Rate for Payer: UnitedHealthcare Medicare	$4.01
Rate for Payer: University Health Alliance Commercial	$5.85

terazosin 1 mg capsule [HHSC]

Facility

$8.93

Service Code	NDC 51079093620
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$8.66
Rate for Payer: AlohaCare Medicaid	$4.46
Rate for Payer: AlohaCare Medicare	$4.46
Rate for Payer: Cash Price	$5.80
Rate for Payer: Devoted Health Medicare	$4.91
Rate for Payer: Hawaii Medical Service Association Medicare	$4.46
Rate for Payer: Hawaii Western Management Group Commercial	$8.48
Rate for Payer: Health Management Network Commercial	$7.59
Rate for Payer: Humana Medicare	$4.46
Rate for Payer: Kaiser Permanente Commercial	$8.04
Rate for Payer: Kaiser Permanente Medicaid	$4.55
Rate for Payer: Kaiser Permanente Medicare	$4.46
Rate for Payer: MDX Hawaii PPO	$8.66
Rate for Payer: Ohana Health Plan Medicaid	$4.46
Rate for Payer: Ohana Health Plan Medicare	$4.46
Rate for Payer: UnitedHealthcare Medicaid	$5.36
Rate for Payer: UnitedHealthcare Medicare	$4.46
Rate for Payer: University Health Alliance Commercial	$6.51

terazosin 1 mg capsule [HHSC]

Facility

$8.92

Service Code	NDC 59746038306
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$8.65
Rate for Payer: AlohaCare Medicaid	$4.46
Rate for Payer: AlohaCare Medicare	$4.46
Rate for Payer: Cash Price	$5.80
Rate for Payer: Devoted Health Medicare	$4.91
Rate for Payer: Hawaii Medical Service Association Medicare	$4.46
Rate for Payer: Hawaii Western Management Group Commercial	$8.47
Rate for Payer: Health Management Network Commercial	$7.58
Rate for Payer: Humana Medicare	$4.46
Rate for Payer: Kaiser Permanente Commercial	$8.03
Rate for Payer: Kaiser Permanente Medicaid	$4.55
Rate for Payer: Kaiser Permanente Medicare	$4.46
Rate for Payer: MDX Hawaii PPO	$8.65
Rate for Payer: Ohana Health Plan Medicaid	$4.46
Rate for Payer: Ohana Health Plan Medicare	$4.46
Rate for Payer: UnitedHealthcare Medicaid	$5.35
Rate for Payer: UnitedHealthcare Medicare	$4.46
Rate for Payer: University Health Alliance Commercial	$6.50

terazosin 1 mg capsule [HHSC]

Facility

$8.93

Service Code	NDC 50268076415
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$8.66
Rate for Payer: AlohaCare Medicaid	$4.46
Rate for Payer: AlohaCare Medicare	$4.46
Rate for Payer: Cash Price	$5.80
Rate for Payer: Devoted Health Medicare	$4.91
Rate for Payer: Hawaii Medical Service Association Medicare	$4.46
Rate for Payer: Hawaii Western Management Group Commercial	$8.48
Rate for Payer: Health Management Network Commercial	$7.59
Rate for Payer: Humana Medicare	$4.46
Rate for Payer: Kaiser Permanente Commercial	$8.04
Rate for Payer: Kaiser Permanente Medicaid	$4.55
Rate for Payer: Kaiser Permanente Medicare	$4.46
Rate for Payer: MDX Hawaii PPO	$8.66
Rate for Payer: Ohana Health Plan Medicaid	$4.46
Rate for Payer: Ohana Health Plan Medicare	$4.46
Rate for Payer: UnitedHealthcare Medicaid	$5.36
Rate for Payer: UnitedHealthcare Medicare	$4.46
Rate for Payer: University Health Alliance Commercial	$6.51

terazosin 1 mg capsule [HHSC]

Facility

$8.93

Service Code	NDC 51079093620
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$8.66
Rate for Payer: Cash Price	$5.80
Rate for Payer: Health Management Network Commercial	$7.59
Rate for Payer: Kaiser Permanente Commercial	$8.04
Rate for Payer: MDX Hawaii PPO	$8.66

terazosin 1 mg capsule [HHSC]

Facility

$8.92

Service Code	NDC 59746038306
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$8.65
Rate for Payer: Cash Price	$5.80
Rate for Payer: Health Management Network Commercial	$7.58
Rate for Payer: Kaiser Permanente Commercial	$8.03
Rate for Payer: MDX Hawaii PPO	$8.65

terazosin 1 mg capsule [HHSC]

Facility

$8.03

Service Code	NDC 00904612661
Hospital Charge Code	2500809
Hospital Revenue Code	250
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$7.79
Rate for Payer: Cash Price	$5.22
Rate for Payer: Health Management Network Commercial	$6.83
Rate for Payer: Kaiser Permanente Commercial	$7.23
Rate for Payer: MDX Hawaii PPO	$7.79

terazosin 5 mg capsule [HHSC]

Facility

$8.92

Service Code	NDC 59746038506
Hospital Charge Code	2500810
Hospital Revenue Code	250
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$8.65
Rate for Payer: Cash Price	$5.80
Rate for Payer: Health Management Network Commercial	$7.58
Rate for Payer: Kaiser Permanente Commercial	$8.03
Rate for Payer: MDX Hawaii PPO	$8.65

terazosin 5 mg capsule [HHSC]

Facility

$8.92

Service Code	NDC 59746038506
Hospital Charge Code	2500810
Hospital Revenue Code	250
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$8.65
Rate for Payer: AlohaCare Medicaid	$4.46
Rate for Payer: AlohaCare Medicare	$4.46
Rate for Payer: Cash Price	$5.80
Rate for Payer: Devoted Health Medicare	$4.91
Rate for Payer: Hawaii Medical Service Association Medicare	$4.46
Rate for Payer: Hawaii Western Management Group Commercial	$8.47
Rate for Payer: Health Management Network Commercial	$7.58
Rate for Payer: Humana Medicare	$4.46
Rate for Payer: Kaiser Permanente Commercial	$8.03
Rate for Payer: Kaiser Permanente Medicaid	$4.55
Rate for Payer: Kaiser Permanente Medicare	$4.46
Rate for Payer: MDX Hawaii PPO	$8.65
Rate for Payer: Ohana Health Plan Medicaid	$4.46
Rate for Payer: Ohana Health Plan Medicare	$4.46
Rate for Payer: UnitedHealthcare Medicaid	$5.35
Rate for Payer: UnitedHealthcare Medicare	$4.46
Rate for Payer: University Health Alliance Commercial	$6.50

terazosin 5 mg capsule [HHSC]

Facility

$8.93

Service Code	NDC 51079093820
Hospital Charge Code	2500810
Hospital Revenue Code	250
Min. Negotiated Rate	$4.46
Max. Negotiated Rate	$8.66
Rate for Payer: AlohaCare Medicaid	$4.46
Rate for Payer: AlohaCare Medicare	$4.46
Rate for Payer: Cash Price	$5.80
Rate for Payer: Devoted Health Medicare	$4.91
Rate for Payer: Hawaii Medical Service Association Medicare	$4.46
Rate for Payer: Hawaii Western Management Group Commercial	$8.48
Rate for Payer: Health Management Network Commercial	$7.59
Rate for Payer: Humana Medicare	$4.46
Rate for Payer: Kaiser Permanente Commercial	$8.04
Rate for Payer: Kaiser Permanente Medicaid	$4.55
Rate for Payer: Kaiser Permanente Medicare	$4.46
Rate for Payer: MDX Hawaii PPO	$8.66
Rate for Payer: Ohana Health Plan Medicaid	$4.46
Rate for Payer: Ohana Health Plan Medicare	$4.46
Rate for Payer: UnitedHealthcare Medicaid	$5.36
Rate for Payer: UnitedHealthcare Medicare	$4.46
Rate for Payer: University Health Alliance Commercial	$6.51

terazosin 5 mg capsule [HHSC]

Facility

$8.93

Service Code	NDC 51079093820
Hospital Charge Code	2500810
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$8.66
Rate for Payer: Cash Price	$5.80
Rate for Payer: Health Management Network Commercial	$7.59
Rate for Payer: Kaiser Permanente Commercial	$8.04
Rate for Payer: MDX Hawaii PPO	$8.66

terbutaline 1 mg/1ml vial [HHSC]

Facility

$108.40

Service Code	HCPCS J3105
Hospital Charge Code	2500811
Hospital Revenue Code	636
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$105.15
Rate for Payer: AlohaCare Medicaid	$54.20
Rate for Payer: AlohaCare Medicaid	$4.33
Rate for Payer: AlohaCare Medicaid	$13.35
Rate for Payer: AlohaCare Medicare	$13.35
Rate for Payer: AlohaCare Medicare	$54.20
Rate for Payer: AlohaCare Medicare	$4.33
Rate for Payer: Cash Price	$17.35
Rate for Payer: Cash Price	$5.64
Rate for Payer: Cash Price	$17.35
Rate for Payer: Cash Price	$70.46
Rate for Payer: Cash Price	$70.46
Rate for Payer: Cash Price	$5.64
Rate for Payer: Devoted Health Medicare	$59.62
Rate for Payer: Devoted Health Medicare	$4.77
Rate for Payer: Devoted Health Medicare	$14.68
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Medicare	$54.20
Rate for Payer: Hawaii Medical Service Association Medicare	$4.33
Rate for Payer: Hawaii Medical Service Association Medicare	$13.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.74
Rate for Payer: Hawaii Western Management Group Commercial	$25.36
Rate for Payer: Hawaii Western Management Group Commercial	$102.98
Rate for Payer: Hawaii Western Management Group Commercial	$8.24
Rate for Payer: Health Management Network Commercial	$7.37
Rate for Payer: Health Management Network Commercial	$92.14
Rate for Payer: Health Management Network Commercial	$22.69
Rate for Payer: Humana Medicare	$54.20
Rate for Payer: Humana Medicare	$13.35
Rate for Payer: Humana Medicare	$4.33
Rate for Payer: Kaiser Permanente Commercial	$97.56
Rate for Payer: Kaiser Permanente Commercial	$24.02
Rate for Payer: Kaiser Permanente Commercial	$7.80
Rate for Payer: Kaiser Permanente Medicaid	$4.42
Rate for Payer: Kaiser Permanente Medicaid	$13.61
Rate for Payer: Kaiser Permanente Medicaid	$55.28
Rate for Payer: Kaiser Permanente Medicare	$54.20
Rate for Payer: Kaiser Permanente Medicare	$13.35
Rate for Payer: Kaiser Permanente Medicare	$4.33
Rate for Payer: MDX Hawaii PPO	$8.41
Rate for Payer: MDX Hawaii PPO	$25.89
Rate for Payer: MDX Hawaii PPO	$105.15
Rate for Payer: Ohana Health Plan Medicaid	$13.35
Rate for Payer: Ohana Health Plan Medicaid	$54.20
Rate for Payer: Ohana Health Plan Medicaid	$4.33
Rate for Payer: Ohana Health Plan Medicare	$13.35
Rate for Payer: Ohana Health Plan Medicare	$54.20
Rate for Payer: Ohana Health Plan Medicare	$4.33
Rate for Payer: UnitedHealthcare Medicaid	$16.01
Rate for Payer: UnitedHealthcare Medicaid	$65.04
Rate for Payer: UnitedHealthcare Medicaid	$5.20
Rate for Payer: UnitedHealthcare Medicare	$13.35
Rate for Payer: UnitedHealthcare Medicare	$54.20
Rate for Payer: UnitedHealthcare Medicare	$4.33
Rate for Payer: University Health Alliance Commercial	$79.01
Rate for Payer: University Health Alliance Commercial	$19.45
Rate for Payer: University Health Alliance Commercial	$6.32

terbutaline 1 mg/1ml vial [HHSC]

Facility

$8.67

Service Code	HCPCS J3105
Hospital Charge Code	2500811
Hospital Revenue Code	250
Min. Negotiated Rate	$7.37
Max. Negotiated Rate	$8.41
Rate for Payer: Cash Price	$5.64
Rate for Payer: Cash Price	$17.35
Rate for Payer: Cash Price	$70.46
Rate for Payer: Health Management Network Commercial	$92.14
Rate for Payer: Health Management Network Commercial	$7.37
Rate for Payer: Health Management Network Commercial	$22.69
Rate for Payer: Kaiser Permanente Commercial	$24.02
Rate for Payer: Kaiser Permanente Commercial	$7.80
Rate for Payer: Kaiser Permanente Commercial	$97.56
Rate for Payer: MDX Hawaii PPO	$25.89
Rate for Payer: MDX Hawaii PPO	$105.15
Rate for Payer: MDX Hawaii PPO	$8.41

TESTES PROCEDURES WITH CC/MCC

Facility

$55,810.74

Service Code	MSDRG 711
Min. Negotiated Rate	$55,810.74
Max. Negotiated Rate	$55,810.74
Rate for Payer: Hawaii Medical Service Association Commercial	$55,810.74

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$39,493.30

Service Code	MSDRG 712
Min. Negotiated Rate	$39,493.30
Max. Negotiated Rate	$39,493.30
Rate for Payer: Hawaii Medical Service Association Commercial	$39,493.30

Testosterone, Free & Total FSI

Facility

$285.00

Service Code	HCPCS 84402
Hospital Charge Code	8118056
Hospital Revenue Code	300
Min. Negotiated Rate	$25.47
Max. Negotiated Rate	$276.45
Rate for Payer: AlohaCare Medicaid	$142.50
Rate for Payer: AlohaCare Medicare	$142.50
Rate for Payer: Cash Price	$185.25
Rate for Payer: Cash Price	$185.25
Rate for Payer: Devoted Health Medicare	$156.75
Rate for Payer: Hawaii Medical Service Association ABD	$35.19
Rate for Payer: Hawaii Medical Service Association Commercial	$31.84
Rate for Payer: Hawaii Medical Service Association Medicare	$142.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.95
Rate for Payer: Hawaii Western Management Group Commercial	$25.47
Rate for Payer: Health Management Network Commercial	$242.25
Rate for Payer: Humana Medicare	$142.50
Rate for Payer: Kaiser Permanente Commercial	$256.50
Rate for Payer: Kaiser Permanente Medicaid	$145.35
Rate for Payer: Kaiser Permanente Medicare	$142.50
Rate for Payer: MDX Hawaii PPO	$276.45
Rate for Payer: Ohana Health Plan Medicaid	$142.50
Rate for Payer: Ohana Health Plan Medicare	$142.50
Rate for Payer: UnitedHealthcare Medicaid	$35.19
Rate for Payer: UnitedHealthcare Medicare	$142.50
Rate for Payer: University Health Alliance Commercial	$65.80

Know your out-of-pocket cost for care.

All Charges