Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Fiber Orange [KMC]

Facility

$3.00

Service Code	NDC 49348009092
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

Fiber Orange [KMC]

Facility

$3.00

Service Code	NDC 49348009092
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

Fibrinogen DLS

Facility

$37.00

Service Code	HCPCS 85384
Hospital Charge Code	422853845
Hospital Revenue Code	305
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$15.54
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.04
Rate for Payer: Devoted Health Medicare	$15.54
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.74
Rate for Payer: Hawaii Medical Service Association Commercial	$12.15
Rate for Payer: Hawaii Medical Service Association Medicare	$15.54
Rate for Payer: Hawaii Western Management Group Commercial	$9.72
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$15.54
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$15.54
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$15.54
Rate for Payer: Ohana Health Plan Medicare	$15.54
Rate for Payer: UnitedHealthcare Medicaid	$11.74
Rate for Payer: UnitedHealthcare Medicare	$15.54
Rate for Payer: University Health Alliance Commercial	$21.96

Fibrinogen DLS

Facility

$37.00

Service Code	HCPCS 85384
Hospital Charge Code	422853845
Hospital Revenue Code	305
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

fidaxomicin 200 mg Tab [KMC]

Facility

$1,127.71

Service Code	NDC 52015008001
Hospital Revenue Code	250
Min. Negotiated Rate	$473.64
Max. Negotiated Rate	$1,093.88
Rate for Payer: AlohaCare Medicaid	$563.86
Rate for Payer: AlohaCare Medicare	$473.64
Rate for Payer: Cash Price	$733.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,037.49
Rate for Payer: Devoted Health Medicare	$473.64
Rate for Payer: Hawaii Medical Service Association Medicare	$473.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.32
Rate for Payer: Health Management Network Commercial	$958.55
Rate for Payer: Humana Medicare	$473.64
Rate for Payer: Kaiser Permanente Commercial	$1,014.94
Rate for Payer: Kaiser Permanente Medicaid	$575.13
Rate for Payer: Kaiser Permanente Medicare	$473.64
Rate for Payer: MDX Hawaii PPO	$1,093.88
Rate for Payer: Ohana Health Plan Medicaid	$473.64
Rate for Payer: Ohana Health Plan Medicare	$473.64
Rate for Payer: UnitedHealthcare Medicaid	$676.63
Rate for Payer: UnitedHealthcare Medicare	$473.64
Rate for Payer: University Health Alliance Commercial	$821.99

fidaxomicin 200 mg Tab [KMC]

Facility

$1,127.71

Service Code	NDC 52015008001
Hospital Revenue Code	250
Min. Negotiated Rate	$958.55
Max. Negotiated Rate	$1,093.88
Rate for Payer: Cash Price	$733.01
Rate for Payer: Health Management Network Commercial	$958.55
Rate for Payer: Kaiser Permanente Commercial	$1,014.94
Rate for Payer: MDX Hawaii PPO	$1,093.88

filgrastim sndz 300 mcg/0.5 mL Sol

Facility

$2,646.34

Service Code	HCPCS Q5101
Hospital Revenue Code	637
Min. Negotiated Rate	$2,249.39
Max. Negotiated Rate	$2,566.95
Rate for Payer: Cash Price	$1,720.12
Rate for Payer: Health Management Network Commercial	$2,249.39
Rate for Payer: Kaiser Permanente Commercial	$2,381.71
Rate for Payer: MDX Hawaii PPO	$2,566.95

filgrastim sndz 300 mcg/0.5 mL Sol

Facility

$2,646.34

Service Code	HCPCS Q5101
Hospital Revenue Code	637
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$2,566.95
Rate for Payer: AlohaCare Medicaid	$1,323.17
Rate for Payer: AlohaCare Medicare	$1,111.46
Rate for Payer: Cash Price	$1,720.12
Rate for Payer: Cash Price	$1,720.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,434.63
Rate for Payer: Devoted Health Medicare	$1,111.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Commercial	$0.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1,111.46
Rate for Payer: Hawaii Western Management Group Commercial	$2,514.02
Rate for Payer: Health Management Network Commercial	$2,249.39
Rate for Payer: Humana Medicare	$1,111.46
Rate for Payer: Kaiser Permanente Commercial	$2,381.71
Rate for Payer: Kaiser Permanente Medicaid	$1,349.63
Rate for Payer: Kaiser Permanente Medicare	$1,111.46
Rate for Payer: MDX Hawaii PPO	$2,566.95
Rate for Payer: Ohana Health Plan Medicaid	$1,111.46
Rate for Payer: Ohana Health Plan Medicare	$1,111.46
Rate for Payer: UnitedHealthcare Medicaid	$0.28
Rate for Payer: UnitedHealthcare Medicare	$1,111.46
Rate for Payer: University Health Alliance Commercial	$1,928.92

finasteride 1 mg Tab [KMC]

Facility

$9.76

Service Code	NDC 65862092790
Hospital Revenue Code	250
Min. Negotiated Rate	$8.30
Max. Negotiated Rate	$9.47
Rate for Payer: Cash Price	$6.34
Rate for Payer: Health Management Network Commercial	$8.30
Rate for Payer: Kaiser Permanente Commercial	$8.78
Rate for Payer: MDX Hawaii PPO	$9.47

finasteride 1 mg Tab [KMC]

Facility

$9.76

Service Code	NDC 65862092790
Hospital Revenue Code	250
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$9.47
Rate for Payer: AlohaCare Medicaid	$4.88
Rate for Payer: AlohaCare Medicare	$4.10
Rate for Payer: Cash Price	$6.34
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.98
Rate for Payer: Devoted Health Medicare	$4.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.10
Rate for Payer: Hawaii Western Management Group Commercial	$9.27
Rate for Payer: Health Management Network Commercial	$8.30
Rate for Payer: Humana Medicare	$4.10
Rate for Payer: Kaiser Permanente Commercial	$8.78
Rate for Payer: Kaiser Permanente Medicaid	$4.98
Rate for Payer: Kaiser Permanente Medicare	$4.10
Rate for Payer: MDX Hawaii PPO	$9.47
Rate for Payer: Ohana Health Plan Medicaid	$4.10
Rate for Payer: Ohana Health Plan Medicare	$4.10
Rate for Payer: UnitedHealthcare Medicaid	$5.86
Rate for Payer: UnitedHealthcare Medicare	$4.10
Rate for Payer: University Health Alliance Commercial	$7.11

finasteride 5 mg Tab [KMC]

Facility

$12.64

Service Code	HCPCS S0138
Hospital Revenue Code	637
Min. Negotiated Rate	$5.31
Max. Negotiated Rate	$12.26
Rate for Payer: AlohaCare Medicaid	$6.32
Rate for Payer: AlohaCare Medicare	$5.31
Rate for Payer: Cash Price	$8.22
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.63
Rate for Payer: Devoted Health Medicare	$5.31
Rate for Payer: Hawaii Medical Service Association Medicare	$5.31
Rate for Payer: Hawaii Western Management Group Commercial	$12.01
Rate for Payer: Health Management Network Commercial	$10.74
Rate for Payer: Humana Medicare	$5.31
Rate for Payer: Kaiser Permanente Commercial	$11.38
Rate for Payer: Kaiser Permanente Medicaid	$6.45
Rate for Payer: Kaiser Permanente Medicare	$5.31
Rate for Payer: MDX Hawaii PPO	$12.26
Rate for Payer: Ohana Health Plan Medicaid	$5.31
Rate for Payer: Ohana Health Plan Medicare	$5.31
Rate for Payer: UnitedHealthcare Medicare	$5.31
Rate for Payer: University Health Alliance Commercial	$9.21

finasteride 5 mg Tab [KMC]

Facility

$12.64

Service Code	HCPCS S0138
Hospital Revenue Code	637
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$12.26
Rate for Payer: Cash Price	$8.22
Rate for Payer: Health Management Network Commercial	$10.74
Rate for Payer: Kaiser Permanente Commercial	$11.38
Rate for Payer: MDX Hawaii PPO	$12.26

FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION

Professional

Both

$540.00

Service Code	HCPCS 10021
Hospital Revenue Code	361
Min. Negotiated Rate	$45.22
Max. Negotiated Rate	$459.00
Rate for Payer: AlohaCare Medicaid	$54.49
Rate for Payer: AlohaCare Medicare	$45.22
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$45.22
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$54.49
Rate for Payer: Hawaii Medical Service Association Commercial	$90.91
Rate for Payer: Hawaii Medical Service Association Medicare	$45.22
Rate for Payer: Hawaii Western Management Group Commercial	$83.72
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$54.26
Rate for Payer: Kaiser Permanente Medicaid	$54.26
Rate for Payer: Kaiser Permanente Medicare	$54.26
Rate for Payer: Ohana Health Plan Medicaid	$54.49
Rate for Payer: Ohana Health Plan Medicare	$45.22
Rate for Payer: UnitedHealthcare Medicaid	$54.49
Rate for Payer: UnitedHealthcare Medicare	$45.22
Rate for Payer: University Health Alliance Commercial	$59.40

finerenone 20 mg Tab [KMC]

Facility

$109.87

Service Code	NDC 50419054101
Hospital Revenue Code	250
Min. Negotiated Rate	$93.39
Max. Negotiated Rate	$106.57
Rate for Payer: Cash Price	$71.42
Rate for Payer: Health Management Network Commercial	$93.39
Rate for Payer: Kaiser Permanente Commercial	$98.88
Rate for Payer: MDX Hawaii PPO	$106.57

finerenone 20 mg Tab [KMC]

Facility

$109.87

Service Code	NDC 50419054101
Hospital Revenue Code	250
Min. Negotiated Rate	$46.15
Max. Negotiated Rate	$106.57
Rate for Payer: AlohaCare Medicaid	$54.94
Rate for Payer: AlohaCare Medicare	$46.15
Rate for Payer: Cash Price	$71.42
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$101.08
Rate for Payer: Devoted Health Medicare	$46.15
Rate for Payer: Hawaii Medical Service Association Medicare	$46.15
Rate for Payer: Hawaii Western Management Group Commercial	$104.38
Rate for Payer: Health Management Network Commercial	$93.39
Rate for Payer: Humana Medicare	$46.15
Rate for Payer: Kaiser Permanente Commercial	$98.88
Rate for Payer: Kaiser Permanente Medicaid	$56.03
Rate for Payer: Kaiser Permanente Medicare	$46.15
Rate for Payer: MDX Hawaii PPO	$106.57
Rate for Payer: Ohana Health Plan Medicaid	$46.15
Rate for Payer: Ohana Health Plan Medicare	$46.15
Rate for Payer: UnitedHealthcare Medicaid	$65.92
Rate for Payer: UnitedHealthcare Medicare	$46.15
Rate for Payer: University Health Alliance Commercial	$80.08

FINGERS MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73140
Hospital Charge Code	424731400
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

FINGERS MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73140
Hospital Charge Code	424731400
Hospital Revenue Code	320
Min. Negotiated Rate	$14.98
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.98
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$14.98
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$54.96

FINGER SPLINT 3"

Facility

$18.00

Hospital Charge Code	8108
Hospital Revenue Code	270
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$7.56
Rate for Payer: Cash Price	$11.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.56
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$7.56
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$7.56
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$7.56
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$7.56
Rate for Payer: Ohana Health Plan Medicare	$7.56
Rate for Payer: UnitedHealthcare Medicare	$7.56
Rate for Payer: University Health Alliance Commercial	$13.12

FINGER SPLINT 3"

Facility

$18.00

Hospital Charge Code	8108
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

FINGER SPLINT 6"

Facility

$18.00

Hospital Charge Code	8109
Hospital Revenue Code	270
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$7.56
Rate for Payer: Cash Price	$11.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.56
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$7.56
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$7.56
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$7.56
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$7.56
Rate for Payer: Ohana Health Plan Medicare	$7.56
Rate for Payer: UnitedHealthcare Medicare	$7.56
Rate for Payer: University Health Alliance Commercial	$13.12

FINGER SPLINT 6"

Facility

$18.00

Hospital Charge Code	8109
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

flecainide 100 mg Tab [KMC]

Facility

$14.32

Service Code	NDC 00054001121
Hospital Revenue Code	250
Min. Negotiated Rate	$6.01
Max. Negotiated Rate	$13.89
Rate for Payer: AlohaCare Medicaid	$7.16
Rate for Payer: AlohaCare Medicare	$6.01
Rate for Payer: Cash Price	$9.31
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.17
Rate for Payer: Devoted Health Medicare	$6.01
Rate for Payer: Hawaii Medical Service Association Medicare	$6.01
Rate for Payer: Hawaii Western Management Group Commercial	$13.60
Rate for Payer: Health Management Network Commercial	$12.17
Rate for Payer: Humana Medicare	$6.01
Rate for Payer: Kaiser Permanente Commercial	$12.89
Rate for Payer: Kaiser Permanente Medicaid	$7.30
Rate for Payer: Kaiser Permanente Medicare	$6.01
Rate for Payer: MDX Hawaii PPO	$13.89
Rate for Payer: Ohana Health Plan Medicaid	$6.01
Rate for Payer: Ohana Health Plan Medicare	$6.01
Rate for Payer: UnitedHealthcare Medicaid	$8.59
Rate for Payer: UnitedHealthcare Medicare	$6.01
Rate for Payer: University Health Alliance Commercial	$10.44

flecainide 100 mg Tab [KMC]

Facility

$14.32

Service Code	NDC 00054001121
Hospital Revenue Code	250
Min. Negotiated Rate	$12.17
Max. Negotiated Rate	$13.89
Rate for Payer: Cash Price	$9.31
Rate for Payer: Health Management Network Commercial	$12.17
Rate for Payer: Kaiser Permanente Commercial	$12.89
Rate for Payer: MDX Hawaii PPO	$13.89

FLEXIBLE ENDOSCOPIC EVAL LARYN SENSORY C/V REC

Professional

Both

$539.00

Service Code	HCPCS 92614
Hospital Revenue Code	440
Min. Negotiated Rate	$54.73
Max. Negotiated Rate	$458.15
Rate for Payer: AlohaCare Medicaid	$66.53
Rate for Payer: AlohaCare Medicare	$54.73
Rate for Payer: Cash Price	$350.35
Rate for Payer: Cash Price	$350.35
Rate for Payer: Devoted Health Medicare	$54.73
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$66.53
Rate for Payer: Hawaii Medical Service Association Medicare	$54.73
Rate for Payer: Hawaii Western Management Group Commercial	$167.11
Rate for Payer: Health Management Network Commercial	$458.15
Rate for Payer: Kaiser Permanente Commercial	$65.68
Rate for Payer: Kaiser Permanente Medicaid	$65.68
Rate for Payer: Kaiser Permanente Medicare	$65.68
Rate for Payer: Ohana Health Plan Medicaid	$66.53
Rate for Payer: Ohana Health Plan Medicare	$54.73
Rate for Payer: UnitedHealthcare Medicaid	$66.53
Rate for Payer: UnitedHealthcare Medicare	$54.73
Rate for Payer: University Health Alliance Commercial	$80.74

FLEXIBLE ENDOSCOPIC EVAL SWALLOW C/V REC

Professional

Both

$731.00

Service Code	HCPCS 92612
Hospital Revenue Code	440
Min. Negotiated Rate	$54.92
Max. Negotiated Rate	$621.35
Rate for Payer: AlohaCare Medicaid	$67.87
Rate for Payer: AlohaCare Medicare	$54.92
Rate for Payer: Cash Price	$475.15
Rate for Payer: Cash Price	$475.15
Rate for Payer: Devoted Health Medicare	$54.92
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$67.87
Rate for Payer: Hawaii Medical Service Association Medicare	$54.92
Rate for Payer: Hawaii Western Management Group Commercial	$199.07
Rate for Payer: Health Management Network Commercial	$621.35
Rate for Payer: Kaiser Permanente Commercial	$65.90
Rate for Payer: Kaiser Permanente Medicaid	$65.90
Rate for Payer: Kaiser Permanente Medicare	$65.90
Rate for Payer: Ohana Health Plan Medicaid	$67.87
Rate for Payer: Ohana Health Plan Medicare	$54.92
Rate for Payer: UnitedHealthcare Medicaid	$67.87
Rate for Payer: UnitedHealthcare Medicare	$54.92

Know your out-of-pocket cost for care.

All Charges