Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

tobra-dex 0.3-0.1% ophth susp 2.5ml [HHSC]

Facility

$208.42

Service Code	NDC 00574403125
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$104.21
Max. Negotiated Rate	$202.17
Rate for Payer: AlohaCare Medicaid	$104.21
Rate for Payer: AlohaCare Medicare	$104.21
Rate for Payer: Cash Price	$135.47
Rate for Payer: Devoted Health Medicare	$114.63
Rate for Payer: Hawaii Medical Service Association Medicare	$104.21
Rate for Payer: Hawaii Western Management Group Commercial	$198.00
Rate for Payer: Health Management Network Commercial	$177.16
Rate for Payer: Humana Medicare	$104.21
Rate for Payer: Kaiser Permanente Commercial	$187.58
Rate for Payer: Kaiser Permanente Medicaid	$106.29
Rate for Payer: Kaiser Permanente Medicare	$104.21
Rate for Payer: MDX Hawaii PPO	$202.17
Rate for Payer: Ohana Health Plan Medicaid	$104.21
Rate for Payer: Ohana Health Plan Medicare	$104.21
Rate for Payer: UnitedHealthcare Medicaid	$125.05
Rate for Payer: UnitedHealthcare Medicare	$104.21
Rate for Payer: University Health Alliance Commercial	$151.92

tobra-dex 0.3-0.1% ophth susp 2.5ml [HHSC]

Facility

$309.20

Service Code	NDC 24208029525
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$154.60
Max. Negotiated Rate	$299.92
Rate for Payer: AlohaCare Medicaid	$154.60
Rate for Payer: AlohaCare Medicare	$154.60
Rate for Payer: Cash Price	$200.98
Rate for Payer: Devoted Health Medicare	$170.06
Rate for Payer: Hawaii Medical Service Association Medicare	$154.60
Rate for Payer: Hawaii Western Management Group Commercial	$293.74
Rate for Payer: Health Management Network Commercial	$262.82
Rate for Payer: Humana Medicare	$154.60
Rate for Payer: Kaiser Permanente Commercial	$278.28
Rate for Payer: Kaiser Permanente Medicaid	$157.69
Rate for Payer: Kaiser Permanente Medicare	$154.60
Rate for Payer: MDX Hawaii PPO	$299.92
Rate for Payer: Ohana Health Plan Medicaid	$154.60
Rate for Payer: Ohana Health Plan Medicare	$154.60
Rate for Payer: UnitedHealthcare Medicaid	$185.52
Rate for Payer: UnitedHealthcare Medicare	$154.60
Rate for Payer: University Health Alliance Commercial	$225.38

tobra-dex 0.3-0.1% ophth susp 2.5ml [HHSC]

Facility

$208.42

Service Code	NDC 00574403125
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$177.16
Max. Negotiated Rate	$202.17
Rate for Payer: Cash Price	$135.47
Rate for Payer: Health Management Network Commercial	$177.16
Rate for Payer: Kaiser Permanente Commercial	$187.58
Rate for Payer: MDX Hawaii PPO	$202.17

tobra-dex 0.3-0.1% ophth susp 2.5ml [HHSC]

Facility

$309.20

Service Code	NDC 24208029525
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$262.82
Max. Negotiated Rate	$299.92
Rate for Payer: Cash Price	$200.98
Rate for Payer: Health Management Network Commercial	$262.82
Rate for Payer: Kaiser Permanente Commercial	$278.28
Rate for Payer: MDX Hawaii PPO	$299.92

tobra-dex 0.3-0.1% ophth susp 2.5ml [HHSC]

Facility

$352.94

Service Code	NDC 61314064725
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$342.35
Rate for Payer: Cash Price	$229.41
Rate for Payer: Health Management Network Commercial	$300.00
Rate for Payer: Kaiser Permanente Commercial	$317.65
Rate for Payer: MDX Hawaii PPO	$342.35

tobra-dexam 0.3-0.1% ophth oint 3.5gm [HHSC]

Facility

$814.35

Service Code	NDC 00078087601
Hospital Charge Code	2500224
Hospital Revenue Code	250
Min. Negotiated Rate	$407.18
Max. Negotiated Rate	$789.92
Rate for Payer: AlohaCare Medicaid	$407.18
Rate for Payer: AlohaCare Medicare	$407.18
Rate for Payer: Cash Price	$529.33
Rate for Payer: Devoted Health Medicare	$447.89
Rate for Payer: Hawaii Medical Service Association Medicare	$407.18
Rate for Payer: Hawaii Western Management Group Commercial	$773.63
Rate for Payer: Health Management Network Commercial	$692.20
Rate for Payer: Humana Medicare	$407.18
Rate for Payer: Kaiser Permanente Commercial	$732.91
Rate for Payer: Kaiser Permanente Medicaid	$415.32
Rate for Payer: Kaiser Permanente Medicare	$407.18
Rate for Payer: MDX Hawaii PPO	$789.92
Rate for Payer: Ohana Health Plan Medicaid	$407.18
Rate for Payer: Ohana Health Plan Medicare	$407.18
Rate for Payer: UnitedHealthcare Medicaid	$488.61
Rate for Payer: UnitedHealthcare Medicare	$407.18
Rate for Payer: University Health Alliance Commercial	$593.58

tobra-dexam 0.3-0.1% ophth oint 3.5gm [HHSC]

Facility

$766.14

Service Code	NDC 00065064835
Hospital Charge Code	2500224
Hospital Revenue Code	250
Min. Negotiated Rate	$383.07
Max. Negotiated Rate	$743.16
Rate for Payer: AlohaCare Medicaid	$383.07
Rate for Payer: AlohaCare Medicare	$383.07
Rate for Payer: Cash Price	$497.99
Rate for Payer: Devoted Health Medicare	$421.38
Rate for Payer: Hawaii Medical Service Association Medicare	$383.07
Rate for Payer: Hawaii Western Management Group Commercial	$727.83
Rate for Payer: Health Management Network Commercial	$651.22
Rate for Payer: Humana Medicare	$383.07
Rate for Payer: Kaiser Permanente Commercial	$689.53
Rate for Payer: Kaiser Permanente Medicaid	$390.73
Rate for Payer: Kaiser Permanente Medicare	$383.07
Rate for Payer: MDX Hawaii PPO	$743.16
Rate for Payer: Ohana Health Plan Medicaid	$383.07
Rate for Payer: Ohana Health Plan Medicare	$383.07
Rate for Payer: UnitedHealthcare Medicaid	$459.68
Rate for Payer: UnitedHealthcare Medicare	$383.07
Rate for Payer: University Health Alliance Commercial	$558.44

tobra-dexam 0.3-0.1% ophth oint 3.5gm [HHSC]

Facility

$766.14

Service Code	NDC 00065064835
Hospital Charge Code	2500224
Hospital Revenue Code	250
Min. Negotiated Rate	$651.22
Max. Negotiated Rate	$743.16
Rate for Payer: Cash Price	$497.99
Rate for Payer: Health Management Network Commercial	$651.22
Rate for Payer: Kaiser Permanente Commercial	$689.53
Rate for Payer: MDX Hawaii PPO	$743.16

tobra-dexam 0.3-0.1% ophth oint 3.5gm [HHSC]

Facility

$814.35

Service Code	NDC 00078087601
Hospital Charge Code	2500224
Hospital Revenue Code	250
Min. Negotiated Rate	$692.20
Max. Negotiated Rate	$789.92
Rate for Payer: Cash Price	$529.33
Rate for Payer: Health Management Network Commercial	$692.20
Rate for Payer: Kaiser Permanente Commercial	$732.91
Rate for Payer: MDX Hawaii PPO	$789.92

tobramycin 0.3% ophth drop [HHSC]

Facility

$77.09

Service Code	NDC 24208029005
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$65.53
Max. Negotiated Rate	$74.78
Rate for Payer: Cash Price	$50.11
Rate for Payer: Health Management Network Commercial	$65.53
Rate for Payer: Kaiser Permanente Commercial	$69.38
Rate for Payer: MDX Hawaii PPO	$74.78

tobramycin 0.3% ophth drop [HHSC]

Facility

$79.01

Service Code	NDC 17478029010
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$39.51
Max. Negotiated Rate	$76.64
Rate for Payer: AlohaCare Medicaid	$39.51
Rate for Payer: AlohaCare Medicare	$39.51
Rate for Payer: Cash Price	$51.36
Rate for Payer: Devoted Health Medicare	$43.46
Rate for Payer: Hawaii Medical Service Association Medicare	$39.51
Rate for Payer: Hawaii Western Management Group Commercial	$75.06
Rate for Payer: Health Management Network Commercial	$67.16
Rate for Payer: Humana Medicare	$39.51
Rate for Payer: Kaiser Permanente Commercial	$71.11
Rate for Payer: Kaiser Permanente Medicaid	$40.30
Rate for Payer: Kaiser Permanente Medicare	$39.51
Rate for Payer: MDX Hawaii PPO	$76.64
Rate for Payer: Ohana Health Plan Medicaid	$39.51
Rate for Payer: Ohana Health Plan Medicare	$39.51
Rate for Payer: UnitedHealthcare Medicaid	$47.41
Rate for Payer: UnitedHealthcare Medicare	$39.51
Rate for Payer: University Health Alliance Commercial	$57.59

tobramycin 0.3% ophth drop [HHSC]

Facility

$77.09

Service Code	NDC 24208029005
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$38.55
Max. Negotiated Rate	$74.78
Rate for Payer: AlohaCare Medicaid	$38.55
Rate for Payer: AlohaCare Medicare	$38.55
Rate for Payer: Cash Price	$50.11
Rate for Payer: Devoted Health Medicare	$42.40
Rate for Payer: Hawaii Medical Service Association Medicare	$38.55
Rate for Payer: Hawaii Western Management Group Commercial	$73.24
Rate for Payer: Health Management Network Commercial	$65.53
Rate for Payer: Humana Medicare	$38.55
Rate for Payer: Kaiser Permanente Commercial	$69.38
Rate for Payer: Kaiser Permanente Medicaid	$39.32
Rate for Payer: Kaiser Permanente Medicare	$38.55
Rate for Payer: MDX Hawaii PPO	$74.78
Rate for Payer: Ohana Health Plan Medicaid	$38.55
Rate for Payer: Ohana Health Plan Medicare	$38.55
Rate for Payer: UnitedHealthcare Medicaid	$46.25
Rate for Payer: UnitedHealthcare Medicare	$38.55
Rate for Payer: University Health Alliance Commercial	$56.19

tobramycin 0.3% ophth drop [HHSC]

Facility

$79.01

Service Code	NDC 17478029010
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$67.16
Max. Negotiated Rate	$76.64
Rate for Payer: Cash Price	$51.36
Rate for Payer: Health Management Network Commercial	$67.16
Rate for Payer: Kaiser Permanente Commercial	$71.11
Rate for Payer: MDX Hawaii PPO	$76.64

tobramycin 0.3% ophth drop [HHSC]

Facility

$40.12

Service Code	NDC 70069013101
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$38.92
Rate for Payer: AlohaCare Medicaid	$20.06
Rate for Payer: AlohaCare Medicare	$20.06
Rate for Payer: Cash Price	$26.08
Rate for Payer: Devoted Health Medicare	$22.07
Rate for Payer: Hawaii Medical Service Association Medicare	$20.06
Rate for Payer: Hawaii Western Management Group Commercial	$38.11
Rate for Payer: Health Management Network Commercial	$34.10
Rate for Payer: Humana Medicare	$20.06
Rate for Payer: Kaiser Permanente Commercial	$36.11
Rate for Payer: Kaiser Permanente Medicaid	$20.46
Rate for Payer: Kaiser Permanente Medicare	$20.06
Rate for Payer: MDX Hawaii PPO	$38.92
Rate for Payer: Ohana Health Plan Medicaid	$20.06
Rate for Payer: Ohana Health Plan Medicare	$20.06
Rate for Payer: UnitedHealthcare Medicaid	$24.07
Rate for Payer: UnitedHealthcare Medicare	$20.06
Rate for Payer: University Health Alliance Commercial	$29.24

tobramycin 0.3% ophth drop [HHSC]

Facility

$160.27

Service Code	NDC 61314064305
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$80.14
Max. Negotiated Rate	$155.46
Rate for Payer: AlohaCare Medicaid	$80.14
Rate for Payer: AlohaCare Medicare	$80.14
Rate for Payer: Cash Price	$104.18
Rate for Payer: Devoted Health Medicare	$88.15
Rate for Payer: Hawaii Medical Service Association Medicare	$80.14
Rate for Payer: Hawaii Western Management Group Commercial	$152.26
Rate for Payer: Health Management Network Commercial	$136.23
Rate for Payer: Humana Medicare	$80.14
Rate for Payer: Kaiser Permanente Commercial	$144.24
Rate for Payer: Kaiser Permanente Medicaid	$81.74
Rate for Payer: Kaiser Permanente Medicare	$80.14
Rate for Payer: MDX Hawaii PPO	$155.46
Rate for Payer: Ohana Health Plan Medicaid	$80.14
Rate for Payer: Ohana Health Plan Medicare	$80.14
Rate for Payer: UnitedHealthcare Medicaid	$96.16
Rate for Payer: UnitedHealthcare Medicare	$80.14
Rate for Payer: University Health Alliance Commercial	$116.82

tobramycin 0.3% ophth drop [HHSC]

Facility

$40.12

Service Code	NDC 70069013101
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$34.10
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$26.08
Rate for Payer: Health Management Network Commercial	$34.10
Rate for Payer: Kaiser Permanente Commercial	$36.11
Rate for Payer: MDX Hawaii PPO	$38.92

tobramycin 0.3% ophth drop [HHSC]

Facility

$160.27

Service Code	NDC 61314064305
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$155.46
Rate for Payer: Cash Price	$104.18
Rate for Payer: Health Management Network Commercial	$136.23
Rate for Payer: Kaiser Permanente Commercial	$144.24
Rate for Payer: MDX Hawaii PPO	$155.46

Topiramate FSI

Facility

$138.00

Service Code	HCPCS 80201
Hospital Charge Code	8118061
Hospital Revenue Code	301
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$133.86
Rate for Payer: AlohaCare Medicaid	$69.00
Rate for Payer: AlohaCare Medicare	$69.00
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$75.90
Rate for Payer: Hawaii Medical Service Association ABD	$16.48
Rate for Payer: Hawaii Medical Service Association Commercial	$14.90
Rate for Payer: Hawaii Medical Service Association Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.30
Rate for Payer: Hawaii Western Management Group Commercial	$11.92
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Humana Medicare	$69.00
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: Kaiser Permanente Medicare	$69.00
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: Ohana Health Plan Medicaid	$69.00
Rate for Payer: Ohana Health Plan Medicare	$69.00
Rate for Payer: UnitedHealthcare Medicaid	$16.48
Rate for Payer: UnitedHealthcare Medicare	$69.00
Rate for Payer: University Health Alliance Commercial	$30.82

Topiramate FSI

Facility

$138.00

Service Code	HCPCS 80201
Hospital Charge Code	8118061
Hospital Revenue Code	301
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$89.70
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: MDX Hawaii PPO	$133.86

torsemide 10 mg tablet [HHSC]

Facility

$3.96

Service Code	NDC 50268075515
Hospital Charge Code	2501151
Hospital Revenue Code	250
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.57
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Kaiser Permanente Commercial	$3.56
Rate for Payer: MDX Hawaii PPO	$3.84

torsemide 10 mg tablet [HHSC]

Facility

$3.96

Service Code	NDC 50268075515
Hospital Charge Code	2501151
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$3.84
Rate for Payer: AlohaCare Medicaid	$1.98
Rate for Payer: AlohaCare Medicare	$1.98
Rate for Payer: Cash Price	$2.57
Rate for Payer: Devoted Health Medicare	$2.18
Rate for Payer: Hawaii Medical Service Association Medicare	$1.98
Rate for Payer: Hawaii Western Management Group Commercial	$3.76
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Humana Medicare	$1.98
Rate for Payer: Kaiser Permanente Commercial	$3.56
Rate for Payer: Kaiser Permanente Medicaid	$2.02
Rate for Payer: Kaiser Permanente Medicare	$1.98
Rate for Payer: MDX Hawaii PPO	$3.84
Rate for Payer: Ohana Health Plan Medicaid	$1.98
Rate for Payer: Ohana Health Plan Medicare	$1.98
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: UnitedHealthcare Medicare	$1.98
Rate for Payer: University Health Alliance Commercial	$2.89

torsemide 10 mg tablet [HHSC]

Facility

$3.91

Service Code	NDC 23155087201
Hospital Charge Code	2501151
Hospital Revenue Code	250
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$3.79
Rate for Payer: Cash Price	$2.54
Rate for Payer: Health Management Network Commercial	$3.32
Rate for Payer: Kaiser Permanente Commercial	$3.52
Rate for Payer: MDX Hawaii PPO	$3.79

torsemide 10 mg tablet [HHSC]

Facility

$3.91

Service Code	NDC 23155087201
Hospital Charge Code	2501151
Hospital Revenue Code	250
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$3.79
Rate for Payer: AlohaCare Medicaid	$1.96
Rate for Payer: AlohaCare Medicare	$1.96
Rate for Payer: Cash Price	$2.54
Rate for Payer: Devoted Health Medicare	$2.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1.96
Rate for Payer: Hawaii Western Management Group Commercial	$3.71
Rate for Payer: Health Management Network Commercial	$3.32
Rate for Payer: Humana Medicare	$1.96
Rate for Payer: Kaiser Permanente Commercial	$3.52
Rate for Payer: Kaiser Permanente Medicaid	$1.99
Rate for Payer: Kaiser Permanente Medicare	$1.96
Rate for Payer: MDX Hawaii PPO	$3.79
Rate for Payer: Ohana Health Plan Medicaid	$1.96
Rate for Payer: Ohana Health Plan Medicare	$1.96
Rate for Payer: UnitedHealthcare Medicaid	$2.35
Rate for Payer: UnitedHealthcare Medicare	$1.96
Rate for Payer: University Health Alliance Commercial	$2.85

torsemide 20 mg tablet [HHSC]

Facility

$4.65

Service Code	NDC 68084053901
Hospital Charge Code	2501152
Hospital Revenue Code	250
Min. Negotiated Rate	$2.33
Max. Negotiated Rate	$4.51
Rate for Payer: AlohaCare Medicaid	$2.33
Rate for Payer: AlohaCare Medicare	$2.33
Rate for Payer: Cash Price	$3.02
Rate for Payer: Devoted Health Medicare	$2.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2.33
Rate for Payer: Hawaii Western Management Group Commercial	$4.42
Rate for Payer: Health Management Network Commercial	$3.95
Rate for Payer: Humana Medicare	$2.33
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: Kaiser Permanente Medicaid	$2.37
Rate for Payer: Kaiser Permanente Medicare	$2.33
Rate for Payer: MDX Hawaii PPO	$4.51
Rate for Payer: Ohana Health Plan Medicaid	$2.33
Rate for Payer: Ohana Health Plan Medicare	$2.33
Rate for Payer: UnitedHealthcare Medicaid	$2.79
Rate for Payer: UnitedHealthcare Medicare	$2.33
Rate for Payer: University Health Alliance Commercial	$3.39

torsemide 20 mg tablet [HHSC]

Facility

$4.65

Service Code	NDC 68084053901
Hospital Charge Code	2501152
Hospital Revenue Code	250
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$4.51
Rate for Payer: Cash Price	$3.02
Rate for Payer: Health Management Network Commercial	$3.95
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: MDX Hawaii PPO	$4.51

Know your out-of-pocket cost for care.

All Charges