Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

acetaminophen-butalbital 325-50 mg Tab [KMC]

Facility

$6.25

Service Code	NDC 47781062801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$6.06
Rate for Payer: AlohaCare Medicaid	$3.12
Rate for Payer: AlohaCare Medicare	$2.62
Rate for Payer: Cash Price	$4.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.75
Rate for Payer: Devoted Health Medicare	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$5.94
Rate for Payer: Health Management Network Commercial	$5.31
Rate for Payer: Humana Medicare	$2.62
Rate for Payer: Kaiser Permanente Commercial	$5.62
Rate for Payer: Kaiser Permanente Medicaid	$3.19
Rate for Payer: Kaiser Permanente Medicare	$2.62
Rate for Payer: MDX Hawaii PPO	$6.06
Rate for Payer: Ohana Health Plan Medicaid	$2.62
Rate for Payer: Ohana Health Plan Medicare	$2.62
Rate for Payer: UnitedHealthcare Medicaid	$3.75
Rate for Payer: UnitedHealthcare Medicare	$2.62
Rate for Payer: University Health Alliance Commercial	$4.56

acetaminophen-butalbital 325-50 mg Tab [KMC]

Facility

$6.25

Service Code	NDC 47781062801
Hospital Revenue Code	250
Min. Negotiated Rate	$5.31
Max. Negotiated Rate	$6.06
Rate for Payer: Cash Price	$4.06
Rate for Payer: Health Management Network Commercial	$5.31
Rate for Payer: Kaiser Permanente Commercial	$5.62
Rate for Payer: MDX Hawaii PPO	$6.06

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq [KMC]

Facility

$0.17

Service Code	NDC 00603102058
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Management Network Commercial	$0.14
Rate for Payer: Kaiser Permanente Commercial	$0.15
Rate for Payer: MDX Hawaii PPO	$0.16

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq [KMC]

Facility

$0.17

Service Code	NDC 00603102058
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: AlohaCare Medicaid	$0.09
Rate for Payer: AlohaCare Medicare	$0.07
Rate for Payer: Cash Price	$0.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.16
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Hawaii Medical Service Association Medicare	$0.07
Rate for Payer: Hawaii Western Management Group Commercial	$0.16
Rate for Payer: Health Management Network Commercial	$0.14
Rate for Payer: Humana Medicare	$0.07
Rate for Payer: Kaiser Permanente Commercial	$0.15
Rate for Payer: Kaiser Permanente Medicaid	$0.09
Rate for Payer: Kaiser Permanente Medicare	$0.07
Rate for Payer: MDX Hawaii PPO	$0.16
Rate for Payer: Ohana Health Plan Medicaid	$0.07
Rate for Payer: Ohana Health Plan Medicare	$0.07
Rate for Payer: UnitedHealthcare Medicaid	$0.10
Rate for Payer: UnitedHealthcare Medicare	$0.07
Rate for Payer: University Health Alliance Commercial	$0.12

acetaminophen-codeine 300-30 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079016120
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen-codeine 300-30 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079016120
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

acetaminophen-HYDROcodone 325-10 mg Tab [KMC]

Facility

$3.83

Service Code	NDC 27808003701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$3.72
Rate for Payer: AlohaCare Medicaid	$1.92
Rate for Payer: AlohaCare Medicare	$1.61
Rate for Payer: Cash Price	$2.49
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.52
Rate for Payer: Devoted Health Medicare	$1.61
Rate for Payer: Hawaii Medical Service Association Medicare	$1.61
Rate for Payer: Hawaii Western Management Group Commercial	$3.64
Rate for Payer: Health Management Network Commercial	$3.26
Rate for Payer: Humana Medicare	$1.61
Rate for Payer: Kaiser Permanente Commercial	$3.45
Rate for Payer: Kaiser Permanente Medicaid	$1.95
Rate for Payer: Kaiser Permanente Medicare	$1.61
Rate for Payer: MDX Hawaii PPO	$3.72
Rate for Payer: Ohana Health Plan Medicaid	$1.61
Rate for Payer: Ohana Health Plan Medicare	$1.61
Rate for Payer: UnitedHealthcare Medicaid	$2.30
Rate for Payer: UnitedHealthcare Medicare	$1.61
Rate for Payer: University Health Alliance Commercial	$2.79

acetaminophen-HYDROcodone 325-10 mg Tab [KMC]

Facility

$3.83

Service Code	NDC 27808003701
Hospital Revenue Code	250
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.72
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Management Network Commercial	$3.26
Rate for Payer: Kaiser Permanente Commercial	$3.45
Rate for Payer: MDX Hawaii PPO	$3.72

acetaminophen-HYDROcodone 325-5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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

acetaminophen-HYDROcodone 325-5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

Acetaminophen Level

Facility

$272.00

Service Code	HCPCS 80329
Hospital Charge Code	422803291
Hospital Revenue Code	301
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$263.84
Rate for Payer: AlohaCare Medicaid	$136.00
Rate for Payer: AlohaCare Medicare	$114.24
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$250.24
Rate for Payer: Devoted Health Medicare	$114.24
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.61
Rate for Payer: Hawaii Medical Service Association Medicare	$114.24
Rate for Payer: Hawaii Western Management Group Commercial	$258.40
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: Humana Medicare	$114.24
Rate for Payer: Kaiser Permanente Commercial	$244.80
Rate for Payer: Kaiser Permanente Medicaid	$138.72
Rate for Payer: Kaiser Permanente Medicare	$114.24
Rate for Payer: MDX Hawaii PPO	$263.84
Rate for Payer: Ohana Health Plan Medicaid	$114.24
Rate for Payer: Ohana Health Plan Medicare	$114.24
Rate for Payer: UnitedHealthcare Medicare	$114.24
Rate for Payer: University Health Alliance Commercial	$198.26

Acetaminophen Level

Facility

$272.00

Service Code	HCPCS 80329
Hospital Charge Code	422803291
Hospital Revenue Code	301
Min. Negotiated Rate	$231.20
Max. Negotiated Rate	$263.84
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Management Network Commercial	$231.20
Rate for Payer: Kaiser Permanente Commercial	$244.80
Rate for Payer: MDX Hawaii PPO	$263.84

acetaminophen-oxyCODONE 325-5 mg Tab [KMC]

Facility

$5.47

Service Code	NDC 31722094901
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$3.56
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Kaiser Permanente Commercial	$4.92
Rate for Payer: MDX Hawaii PPO	$5.31

acetaminophen-oxyCODONE 325-5 mg Tab [KMC]

Facility

$5.47

Service Code	NDC 31722094901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$5.31
Rate for Payer: AlohaCare Medicaid	$2.73
Rate for Payer: AlohaCare Medicare	$2.30
Rate for Payer: Cash Price	$3.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.03
Rate for Payer: Devoted Health Medicare	$2.30
Rate for Payer: Hawaii Medical Service Association Medicare	$2.30
Rate for Payer: Hawaii Western Management Group Commercial	$5.20
Rate for Payer: Health Management Network Commercial	$4.65
Rate for Payer: Humana Medicare	$2.30
Rate for Payer: Kaiser Permanente Commercial	$4.92
Rate for Payer: Kaiser Permanente Medicaid	$2.79
Rate for Payer: Kaiser Permanente Medicare	$2.30
Rate for Payer: MDX Hawaii PPO	$5.31
Rate for Payer: Ohana Health Plan Medicaid	$2.30
Rate for Payer: Ohana Health Plan Medicare	$2.30
Rate for Payer: UnitedHealthcare Medicaid	$3.28
Rate for Payer: UnitedHealthcare Medicare	$2.30
Rate for Payer: University Health Alliance Commercial	$3.99

acetaminophen-phenylephrine 325 mg-5 mg Tab

Facility

$3.00

Service Code	NDC 50580054725
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen-phenylephrine 325 mg-5 mg Tab

Facility

$3.00

Service Code	NDC 50580054725
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

Acetaminophen (Tylenol) DLS

Facility

$87.00

Service Code	HCPCS 80329
Hospital Charge Code	422803295Â
Hospital Revenue Code	301
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

Acetaminophen (Tylenol) DLS

Facility

$87.00

Service Code	HCPCS 80329
Hospital Charge Code	422803295Â
Hospital Revenue Code	301
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$36.54
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$80.04
Rate for Payer: Devoted Health Medicare	$36.54
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.61
Rate for Payer: Hawaii Medical Service Association Medicare	$36.54
Rate for Payer: Hawaii Western Management Group Commercial	$82.65
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$36.54
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$36.54
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$36.54
Rate for Payer: Ohana Health Plan Medicare	$36.54
Rate for Payer: UnitedHealthcare Medicare	$36.54
Rate for Payer: University Health Alliance Commercial	$63.41

acetaZOLAMIDE 250 mg Tab [KMC]

Facility

$17.33

Service Code	NDC 00904666361
Hospital Revenue Code	250
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$16.81
Rate for Payer: Cash Price	$11.26
Rate for Payer: Health Management Network Commercial	$14.73
Rate for Payer: Kaiser Permanente Commercial	$15.60
Rate for Payer: MDX Hawaii PPO	$16.81

acetaZOLAMIDE 250 mg Tab [KMC]

Facility

$17.33

Service Code	NDC 00904666361
Hospital Revenue Code	250
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$16.81
Rate for Payer: AlohaCare Medicaid	$8.66
Rate for Payer: AlohaCare Medicare	$7.28
Rate for Payer: Cash Price	$11.26
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.94
Rate for Payer: Devoted Health Medicare	$7.28
Rate for Payer: Hawaii Medical Service Association Medicare	$7.28
Rate for Payer: Hawaii Western Management Group Commercial	$16.46
Rate for Payer: Health Management Network Commercial	$14.73
Rate for Payer: Humana Medicare	$7.28
Rate for Payer: Kaiser Permanente Commercial	$15.60
Rate for Payer: Kaiser Permanente Medicaid	$8.84
Rate for Payer: Kaiser Permanente Medicare	$7.28
Rate for Payer: MDX Hawaii PPO	$16.81
Rate for Payer: Ohana Health Plan Medicaid	$7.28
Rate for Payer: Ohana Health Plan Medicare	$7.28
Rate for Payer: UnitedHealthcare Medicaid	$10.40
Rate for Payer: UnitedHealthcare Medicare	$7.28
Rate for Payer: University Health Alliance Commercial	$12.63

acetic acid topical 0.25% Soln [KMC]

Facility

$0.02

Service Code	NDC 00990614309
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.02
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$0.02
Rate for Payer: Health Management Network Commercial	$0.02
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.02
Rate for Payer: Kaiser Permanente Medicaid	$0.01
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.02
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.01

acetic acid topical 0.25% Soln [KMC]

Facility

$0.02

Service Code	NDC 00990614309
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.02
Rate for Payer: Kaiser Permanente Commercial	$0.02
Rate for Payer: MDX Hawaii PPO	$0.02

Acetone Ql

Facility

$95.00

Service Code	HCPCS 82009
Hospital Charge Code	422820090
Hospital Revenue Code	301
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

Acetone Ql

Facility

$95.00

Service Code	HCPCS 82009
Hospital Charge Code	422820090
Hospital Revenue Code	301
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$39.90
Rate for Payer: Cash Price	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$87.40
Rate for Payer: Devoted Health Medicare	$39.90
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.25
Rate for Payer: Hawaii Medical Service Association Commercial	$5.65
Rate for Payer: Hawaii Medical Service Association Medicare	$39.90
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$39.90
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$39.90
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$39.90
Rate for Payer: Ohana Health Plan Medicare	$39.90
Rate for Payer: UnitedHealthcare Medicaid	$6.25
Rate for Payer: UnitedHealthcare Medicare	$39.90
Rate for Payer: University Health Alliance Commercial	$11.67

acetylcysteine 20% Neb Soln [KMC]

Facility

$15.83

Service Code	HCPCS J7608
Hospital Revenue Code	636
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$15.36
Rate for Payer: Cash Price	$10.29
Rate for Payer: Health Management Network Commercial	$13.46
Rate for Payer: Kaiser Permanente Commercial	$14.25
Rate for Payer: MDX Hawaii PPO	$15.36

Know your out-of-pocket cost for care.

All Charges