Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$9,815.96

Service Code	MSDRG 121
Min. Negotiated Rate	$9,815.96
Max. Negotiated Rate	$9,815.96
Rate for Payer: Hawaii Medical Service Association Commercial	$9,815.96

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$9,815.96

Service Code	MSDRG 122
Min. Negotiated Rate	$9,815.96
Max. Negotiated Rate	$9,815.96
Rate for Payer: Hawaii Medical Service Association Commercial	$9,815.96

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$31,130.62

Service Code	MSDRG 281
Min. Negotiated Rate	$31,130.62
Max. Negotiated Rate	$31,130.62
Rate for Payer: Hawaii Medical Service Association Commercial	$31,130.62

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$36,000.35

Service Code	MSDRG 280
Min. Negotiated Rate	$36,000.35
Max. Negotiated Rate	$36,000.35
Rate for Payer: Hawaii Medical Service Association Commercial	$36,000.35

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$27,255.22

Service Code	MSDRG 282
Min. Negotiated Rate	$27,255.22
Max. Negotiated Rate	$27,255.22
Rate for Payer: Hawaii Medical Service Association Commercial	$27,255.22

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$60,145.06

Service Code	MSDRG 284
Min. Negotiated Rate	$60,145.06
Max. Negotiated Rate	$60,145.06
Rate for Payer: Hawaii Medical Service Association Commercial	$60,145.06

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$60,145.06

Service Code	MSDRG 283
Min. Negotiated Rate	$60,145.06
Max. Negotiated Rate	$60,145.06
Rate for Payer: Hawaii Medical Service Association Commercial	$60,145.06

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$60,145.06

Service Code	MSDRG 285
Min. Negotiated Rate	$60,145.06
Max. Negotiated Rate	$60,145.06
Rate for Payer: Hawaii Medical Service Association Commercial	$60,145.06

acyclovir 500 mg/10mL vial [HHSC]

Facility

$95.15

Service Code	HCPCS J0133
Hospital Charge Code	2500023
Hospital Revenue Code	250
Min. Negotiated Rate	$80.88
Max. Negotiated Rate	$92.30
Rate for Payer: Cash Price	$61.85
Rate for Payer: Cash Price	$55.27
Rate for Payer: Cash Price	$73.09
Rate for Payer: Health Management Network Commercial	$95.58
Rate for Payer: Health Management Network Commercial	$80.88
Rate for Payer: Health Management Network Commercial	$72.28
Rate for Payer: Kaiser Permanente Commercial	$76.53
Rate for Payer: Kaiser Permanente Commercial	$85.64
Rate for Payer: Kaiser Permanente Commercial	$101.20
Rate for Payer: MDX Hawaii PPO	$82.48
Rate for Payer: MDX Hawaii PPO	$109.08
Rate for Payer: MDX Hawaii PPO	$92.30

acyclovir 500 mg/10mL vial [HHSC]

Facility

$112.45

Service Code	HCPCS J0133
Hospital Charge Code	2500023
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$109.08
Rate for Payer: AlohaCare Medicaid	$56.23
Rate for Payer: AlohaCare Medicaid	$47.58
Rate for Payer: AlohaCare Medicaid	$42.52
Rate for Payer: AlohaCare Medicare	$42.52
Rate for Payer: AlohaCare Medicare	$56.23
Rate for Payer: AlohaCare Medicare	$47.58
Rate for Payer: Cash Price	$55.27
Rate for Payer: Cash Price	$61.85
Rate for Payer: Cash Price	$55.27
Rate for Payer: Cash Price	$73.09
Rate for Payer: Cash Price	$73.09
Rate for Payer: Cash Price	$61.85
Rate for Payer: Devoted Health Medicare	$61.85
Rate for Payer: Devoted Health Medicare	$52.33
Rate for Payer: Devoted Health Medicare	$46.77
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$56.23
Rate for Payer: Hawaii Medical Service Association Medicare	$47.58
Rate for Payer: Hawaii Medical Service Association Medicare	$42.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$80.78
Rate for Payer: Hawaii Western Management Group Commercial	$106.83
Rate for Payer: Hawaii Western Management Group Commercial	$90.39
Rate for Payer: Health Management Network Commercial	$80.88
Rate for Payer: Health Management Network Commercial	$95.58
Rate for Payer: Health Management Network Commercial	$72.28
Rate for Payer: Humana Medicare	$56.23
Rate for Payer: Humana Medicare	$42.52
Rate for Payer: Humana Medicare	$47.58
Rate for Payer: Kaiser Permanente Commercial	$101.20
Rate for Payer: Kaiser Permanente Commercial	$76.53
Rate for Payer: Kaiser Permanente Commercial	$85.64
Rate for Payer: Kaiser Permanente Medicaid	$48.53
Rate for Payer: Kaiser Permanente Medicaid	$43.37
Rate for Payer: Kaiser Permanente Medicaid	$57.35
Rate for Payer: Kaiser Permanente Medicare	$56.23
Rate for Payer: Kaiser Permanente Medicare	$42.52
Rate for Payer: Kaiser Permanente Medicare	$47.58
Rate for Payer: MDX Hawaii PPO	$92.30
Rate for Payer: MDX Hawaii PPO	$82.48
Rate for Payer: MDX Hawaii PPO	$109.08
Rate for Payer: Ohana Health Plan Medicaid	$42.52
Rate for Payer: Ohana Health Plan Medicaid	$56.23
Rate for Payer: Ohana Health Plan Medicaid	$47.58
Rate for Payer: Ohana Health Plan Medicare	$42.52
Rate for Payer: Ohana Health Plan Medicare	$56.23
Rate for Payer: Ohana Health Plan Medicare	$47.58
Rate for Payer: UnitedHealthcare Medicaid	$51.02
Rate for Payer: UnitedHealthcare Medicaid	$67.47
Rate for Payer: UnitedHealthcare Medicaid	$57.09
Rate for Payer: UnitedHealthcare Medicare	$42.52
Rate for Payer: UnitedHealthcare Medicare	$56.23
Rate for Payer: UnitedHealthcare Medicare	$47.58
Rate for Payer: University Health Alliance Commercial	$81.96
Rate for Payer: University Health Alliance Commercial	$61.98
Rate for Payer: University Health Alliance Commercial	$69.35

Add-On Anti Smith/Rnp SO FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8301511
Hospital Revenue Code	302
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

Add-On Anti Smith/Rnp SO FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8301511
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicaid	$24.78
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$46.36

Add-On Bordetella Pertuss Amp Prb FSI

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	8301524
Hospital Revenue Code	306
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$237.25
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: MDX Hawaii PPO	$354.05

Add-On Bordetella Pertuss Amp Prb FSI

Facility

$365.00

Service Code	HCPCS 87798
Hospital Charge Code	8301524
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$354.05
Rate for Payer: AlohaCare Medicaid	$182.50
Rate for Payer: AlohaCare Medicare	$182.50
Rate for Payer: Cash Price	$237.25
Rate for Payer: Cash Price	$237.25
Rate for Payer: Devoted Health Medicare	$200.75
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$182.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Humana Medicare	$182.50
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: Kaiser Permanente Medicare	$182.50
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: Ohana Health Plan Medicaid	$182.50
Rate for Payer: Ohana Health Plan Medicare	$182.50
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$182.50
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On Cardiolipin Ab IgG FSI

Facility

$174.00

Service Code	HCPCS 86147
Hospital Charge Code	8335809
Hospital Revenue Code	302
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: MDX Hawaii PPO	$168.78

Add-On Cardiolipin Ab IgG FSI

Facility

$174.00

Service Code	HCPCS 86147
Hospital Charge Code	8335809
Hospital Revenue Code	302
Min. Negotiated Rate	$25.45
Max. Negotiated Rate	$168.78
Rate for Payer: AlohaCare Medicaid	$87.00
Rate for Payer: AlohaCare Medicare	$87.00
Rate for Payer: Cash Price	$113.10
Rate for Payer: Cash Price	$113.10
Rate for Payer: Devoted Health Medicare	$95.70
Rate for Payer: Hawaii Medical Service Association ABD	$35.16
Rate for Payer: Hawaii Medical Service Association Commercial	$31.81
Rate for Payer: Hawaii Medical Service Association Medicare	$87.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.92
Rate for Payer: Hawaii Western Management Group Commercial	$25.45
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Humana Medicare	$87.00
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: Kaiser Permanente Medicare	$87.00
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: Ohana Health Plan Medicaid	$87.00
Rate for Payer: Ohana Health Plan Medicare	$87.00
Rate for Payer: UnitedHealthcare Medicaid	$35.16
Rate for Payer: UnitedHealthcare Medicare	$87.00
Rate for Payer: University Health Alliance Commercial	$65.75

Add-On C Difficile GDH AG SO FSI

Facility

$245.00

Service Code	HCPCS 87449
Hospital Charge Code	8301508
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$237.65
Rate for Payer: AlohaCare Medicaid	$122.50
Rate for Payer: AlohaCare Medicare	$122.50
Rate for Payer: Cash Price	$159.25
Rate for Payer: Cash Price	$159.25
Rate for Payer: Devoted Health Medicare	$134.75
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$14.97
Rate for Payer: Hawaii Medical Service Association Medicare	$122.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$11.98
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Humana Medicare	$122.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$124.95
Rate for Payer: Kaiser Permanente Medicare	$122.50
Rate for Payer: MDX Hawaii PPO	$237.65
Rate for Payer: Ohana Health Plan Medicaid	$122.50
Rate for Payer: Ohana Health Plan Medicare	$122.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$122.50
Rate for Payer: University Health Alliance Commercial	$31.01

Add-On C Difficile GDH AG SO FSI

Facility

$245.00

Service Code	HCPCS 87449
Hospital Charge Code	8301508
Hospital Revenue Code	306
Min. Negotiated Rate	$208.25
Max. Negotiated Rate	$237.65
Rate for Payer: Cash Price	$159.25
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: MDX Hawaii PPO	$237.65

Add-On Chlamydia Pneumo Amp Prb FSI

Facility

$321.00

Service Code	HCPCS 87486
Hospital Charge Code	8301525
Hospital Revenue Code	306
Min. Negotiated Rate	$29.42
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: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association ABD	$29.42
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.48
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
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 Medicaid	$29.42
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On Chlamydia Pneumo Amp Prb FSI

Facility

$321.00

Service Code	HCPCS 87486
Hospital Charge Code	8301525
Hospital Revenue Code	306
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

Add-On Creatinine Ur Random KSO FSI

Facility

$269.00

Service Code	HCPCS 82570
Hospital Charge Code	8301519
Hospital Revenue Code	301
Min. Negotiated Rate	$228.65
Max. Negotiated Rate	$260.93
Rate for Payer: Cash Price	$174.85
Rate for Payer: Health Management Network Commercial	$228.65
Rate for Payer: Kaiser Permanente Commercial	$242.10
Rate for Payer: MDX Hawaii PPO	$260.93

Add-On Creatinine Ur Random KSO FSI

Facility

$269.00

Service Code	HCPCS 82570
Hospital Charge Code	8301519
Hospital Revenue Code	301
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$260.93
Rate for Payer: AlohaCare Medicaid	$134.50
Rate for Payer: AlohaCare Medicare	$134.50
Rate for Payer: Cash Price	$174.85
Rate for Payer: Cash Price	$174.85
Rate for Payer: Devoted Health Medicare	$147.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$134.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$228.65
Rate for Payer: Humana Medicare	$134.50
Rate for Payer: Kaiser Permanente Commercial	$242.10
Rate for Payer: Kaiser Permanente Medicaid	$137.19
Rate for Payer: Kaiser Permanente Medicare	$134.50
Rate for Payer: MDX Hawaii PPO	$260.93
Rate for Payer: Ohana Health Plan Medicaid	$134.50
Rate for Payer: Ohana Health Plan Medicare	$134.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$134.50
Rate for Payer: University Health Alliance Commercial	$13.38

Add-On Culture CMV Shell Vial SO

Facility

$243.00

Service Code	HCPCS 87254
Hospital Charge Code	8301530
Hospital Revenue Code	306
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$157.95
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: MDX Hawaii PPO	$235.71

Add-On Culture CMV Shell Vial SO

Facility

$243.00

Service Code	HCPCS 87254
Hospital Charge Code	8301530
Hospital Revenue Code	306
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$235.71
Rate for Payer: AlohaCare Medicaid	$121.50
Rate for Payer: AlohaCare Medicare	$121.50
Rate for Payer: Cash Price	$157.95
Rate for Payer: Cash Price	$157.95
Rate for Payer: Devoted Health Medicare	$133.65
Rate for Payer: Hawaii Medical Service Association ABD	$16.39
Rate for Payer: Hawaii Medical Service Association Commercial	$24.45
Rate for Payer: Hawaii Medical Service Association Medicare	$121.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.56
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Humana Medicare	$121.50
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: Kaiser Permanente Medicaid	$123.93
Rate for Payer: Kaiser Permanente Medicare	$121.50
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: Ohana Health Plan Medicaid	$121.50
Rate for Payer: Ohana Health Plan Medicare	$121.50
Rate for Payer: UnitedHealthcare Medicaid	$16.39
Rate for Payer: UnitedHealthcare Medicare	$121.50
Rate for Payer: University Health Alliance Commercial	$50.54

Add-On Culture Stool Campy KSO FSI

Facility

$139.00

Service Code	HCPCS 87899
Hospital Charge Code	8301528
Hospital Revenue Code	306
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Know your out-of-pocket cost for care.

All Charges