Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

fluticasone-vilanterol 100-25 mcg inhaler [KMC]

Facility

$25.35

Service Code	NDC 00173085914
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$24.59
Rate for Payer: AlohaCare Medicaid	$12.68
Rate for Payer: AlohaCare Medicare	$10.65
Rate for Payer: Cash Price	$16.48
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$23.32
Rate for Payer: Devoted Health Medicare	$10.65
Rate for Payer: Hawaii Medical Service Association Medicare	$10.65
Rate for Payer: Hawaii Western Management Group Commercial	$24.08
Rate for Payer: Health Management Network Commercial	$21.55
Rate for Payer: Humana Medicare	$10.65
Rate for Payer: Kaiser Permanente Commercial	$22.82
Rate for Payer: Kaiser Permanente Medicaid	$12.93
Rate for Payer: Kaiser Permanente Medicare	$10.65
Rate for Payer: MDX Hawaii PPO	$24.59
Rate for Payer: Ohana Health Plan Medicaid	$10.65
Rate for Payer: Ohana Health Plan Medicare	$10.65
Rate for Payer: UnitedHealthcare Medicaid	$15.21
Rate for Payer: UnitedHealthcare Medicare	$10.65
Rate for Payer: University Health Alliance Commercial	$18.48

fluticasone-vilanterol 100-25 mcg inhaler [KMC]

Facility

$25.35

Service Code	NDC 00173085914
Hospital Revenue Code	250
Min. Negotiated Rate	$21.55
Max. Negotiated Rate	$24.59
Rate for Payer: Cash Price	$16.48
Rate for Payer: Health Management Network Commercial	$21.55
Rate for Payer: Kaiser Permanente Commercial	$22.82
Rate for Payer: MDX Hawaii PPO	$24.59

fluticasone-vilanterol 200-25 mcg inhaler [KMC]

Facility

$25.35

Service Code	NDC 00173088214
Hospital Revenue Code	250
Min. Negotiated Rate	$21.55
Max. Negotiated Rate	$24.59
Rate for Payer: Cash Price	$16.48
Rate for Payer: Health Management Network Commercial	$21.55
Rate for Payer: Kaiser Permanente Commercial	$22.82
Rate for Payer: MDX Hawaii PPO	$24.59

fluticasone-vilanterol 200-25 mcg inhaler [KMC]

Facility

$25.35

Service Code	NDC 00173088214
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$24.59
Rate for Payer: AlohaCare Medicaid	$12.68
Rate for Payer: AlohaCare Medicare	$10.65
Rate for Payer: Cash Price	$16.48
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$23.32
Rate for Payer: Devoted Health Medicare	$10.65
Rate for Payer: Hawaii Medical Service Association Medicare	$10.65
Rate for Payer: Hawaii Western Management Group Commercial	$24.08
Rate for Payer: Health Management Network Commercial	$21.55
Rate for Payer: Humana Medicare	$10.65
Rate for Payer: Kaiser Permanente Commercial	$22.82
Rate for Payer: Kaiser Permanente Medicaid	$12.93
Rate for Payer: Kaiser Permanente Medicare	$10.65
Rate for Payer: MDX Hawaii PPO	$24.59
Rate for Payer: Ohana Health Plan Medicaid	$10.65
Rate for Payer: Ohana Health Plan Medicare	$10.65
Rate for Payer: UnitedHealthcare Medicaid	$15.21
Rate for Payer: UnitedHealthcare Medicare	$10.65
Rate for Payer: University Health Alliance Commercial	$18.48

fluvoxaMINE 50 mg Tab [KMC]

Facility

$10.29

Service Code	NDC 60505016501
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$9.98
Rate for Payer: AlohaCare Medicaid	$5.14
Rate for Payer: AlohaCare Medicare	$4.32
Rate for Payer: Cash Price	$6.69
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.47
Rate for Payer: Devoted Health Medicare	$4.32
Rate for Payer: Hawaii Medical Service Association Medicare	$4.32
Rate for Payer: Hawaii Western Management Group Commercial	$9.78
Rate for Payer: Health Management Network Commercial	$8.75
Rate for Payer: Humana Medicare	$4.32
Rate for Payer: Kaiser Permanente Commercial	$9.26
Rate for Payer: Kaiser Permanente Medicaid	$5.25
Rate for Payer: Kaiser Permanente Medicare	$4.32
Rate for Payer: MDX Hawaii PPO	$9.98
Rate for Payer: Ohana Health Plan Medicaid	$4.32
Rate for Payer: Ohana Health Plan Medicare	$4.32
Rate for Payer: UnitedHealthcare Medicaid	$6.17
Rate for Payer: UnitedHealthcare Medicare	$4.32
Rate for Payer: University Health Alliance Commercial	$7.50

fluvoxaMINE 50 mg Tab [KMC]

Facility

$10.29

Service Code	NDC 60505016501
Hospital Revenue Code	250
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$9.98
Rate for Payer: Cash Price	$6.69
Rate for Payer: Health Management Network Commercial	$8.75
Rate for Payer: Kaiser Permanente Commercial	$9.26
Rate for Payer: MDX Hawaii PPO	$9.98

FO CF EXT/FLX REST 8 Occupational

Facility

$287.00

Service Code	HCPCS L3935
Hospital Charge Code	432L39350
Hospital Revenue Code	274
Min. Negotiated Rate	$160.72
Max. Negotiated Rate	$278.39
Rate for Payer: Cash Price	$186.55
Rate for Payer: Hawaii Western Management Group Commercial	$200.90
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: University Health Alliance Commercial	$160.72

FO CF EXT/FLX REST 8 Occupational

Facility

$287.00

Service Code	HCPCS L3935
Hospital Charge Code	432L39350
Hospital Revenue Code	274
Min. Negotiated Rate	$94.79
Max. Negotiated Rate	$278.39
Rate for Payer: AlohaCare Medicaid	$143.50
Rate for Payer: AlohaCare Medicare	$120.54
Rate for Payer: Cash Price	$186.55
Rate for Payer: Cash Price	$186.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$264.04
Rate for Payer: Devoted Health Medicare	$120.54
Rate for Payer: Hawaii Medical Service Association Medicare	$120.54
Rate for Payer: Hawaii Western Management Group Commercial	$200.90
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Humana Medicare	$120.54
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: Kaiser Permanente Medicaid	$146.37
Rate for Payer: Kaiser Permanente Medicare	$120.54
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: Ohana Health Plan Medicaid	$120.54
Rate for Payer: Ohana Health Plan Medicare	$120.54
Rate for Payer: UnitedHealthcare Medicaid	$94.79
Rate for Payer: UnitedHealthcare Medicare	$120.54
Rate for Payer: University Health Alliance Commercial	$160.72

FO CF PULL RNG BDDY STRPS Occupational

Facility

$287.00

Service Code	HCPCS L3933
Hospital Charge Code	432L39330
Hospital Revenue Code	274
Min. Negotiated Rate	$160.72
Max. Negotiated Rate	$278.39
Rate for Payer: Cash Price	$186.55
Rate for Payer: Hawaii Western Management Group Commercial	$200.90
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: University Health Alliance Commercial	$160.72

FO CF PULL RNG BDDY STRPS Occupational

Facility

$287.00

Service Code	HCPCS L3933
Hospital Charge Code	432L39330
Hospital Revenue Code	274
Min. Negotiated Rate	$91.55
Max. Negotiated Rate	$278.39
Rate for Payer: AlohaCare Medicaid	$143.50
Rate for Payer: AlohaCare Medicare	$120.54
Rate for Payer: Cash Price	$186.55
Rate for Payer: Cash Price	$186.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$264.04
Rate for Payer: Devoted Health Medicare	$120.54
Rate for Payer: Hawaii Medical Service Association Medicare	$120.54
Rate for Payer: Hawaii Western Management Group Commercial	$200.90
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Humana Medicare	$120.54
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: Kaiser Permanente Medicaid	$146.37
Rate for Payer: Kaiser Permanente Medicare	$120.54
Rate for Payer: MDX Hawaii PPO	$278.39
Rate for Payer: Ohana Health Plan Medicaid	$120.54
Rate for Payer: Ohana Health Plan Medicare	$120.54
Rate for Payer: UnitedHealthcare Medicaid	$91.55
Rate for Payer: UnitedHealthcare Medicare	$120.54
Rate for Payer: University Health Alliance Commercial	$160.72

FOERSTER SPONGE FORCEPS 9.5"

Facility

$73.00

Hospital Charge Code	8543
Hospital Revenue Code	270
Min. Negotiated Rate	$30.66
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$30.66
Rate for Payer: Cash Price	$47.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$67.16
Rate for Payer: Devoted Health Medicare	$30.66
Rate for Payer: Hawaii Medical Service Association Medicare	$30.66
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$30.66
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$30.66
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$30.66
Rate for Payer: Ohana Health Plan Medicare	$30.66
Rate for Payer: UnitedHealthcare Medicare	$30.66
Rate for Payer: University Health Alliance Commercial	$53.21

FOERSTER SPONGE FORCEPS 9.5"

Facility

$73.00

Hospital Charge Code	8543
Hospital Revenue Code	270
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$47.45
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

FOERSTER SPONGE FORCEPS 9.5" 12.5CM

Facility

$2.00

Hospital Charge Code	8555
Hospital Revenue Code	270
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

FOERSTER SPONGE FORCEPS 9.5" 12.5CM

Facility

$2.00

Hospital Charge Code	8555
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

Folate Lvl

Facility

$155.00

Service Code	HCPCS 82746
Hospital Charge Code	422827460
Hospital Revenue Code	301
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$65.10
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$142.60
Rate for Payer: Devoted Health Medicare	$65.10
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.32
Rate for Payer: Hawaii Medical Service Association Commercial	$18.38
Rate for Payer: Hawaii Medical Service Association Medicare	$65.10
Rate for Payer: Hawaii Western Management Group Commercial	$14.70
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$65.10
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$65.10
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$65.10
Rate for Payer: Ohana Health Plan Medicare	$65.10
Rate for Payer: UnitedHealthcare Medicaid	$20.32
Rate for Payer: UnitedHealthcare Medicare	$65.10
Rate for Payer: University Health Alliance Commercial	$38.00

Folate Lvl

Facility

$155.00

Service Code	HCPCS 82746
Hospital Charge Code	422827460
Hospital Revenue Code	301
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

Folate, Serum DLS

Facility

$155.00

Service Code	HCPCS 82746
Hospital Charge Code	422827465
Hospital Revenue Code	301
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$150.35
Rate for Payer: AlohaCare Medicaid	$77.50
Rate for Payer: AlohaCare Medicare	$65.10
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$142.60
Rate for Payer: Devoted Health Medicare	$65.10
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.32
Rate for Payer: Hawaii Medical Service Association Commercial	$18.38
Rate for Payer: Hawaii Medical Service Association Medicare	$65.10
Rate for Payer: Hawaii Western Management Group Commercial	$14.70
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Humana Medicare	$65.10
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: Kaiser Permanente Medicaid	$79.05
Rate for Payer: Kaiser Permanente Medicare	$65.10
Rate for Payer: MDX Hawaii PPO	$150.35
Rate for Payer: Ohana Health Plan Medicaid	$65.10
Rate for Payer: Ohana Health Plan Medicare	$65.10
Rate for Payer: UnitedHealthcare Medicaid	$20.32
Rate for Payer: UnitedHealthcare Medicare	$65.10
Rate for Payer: University Health Alliance Commercial	$38.00

Folate, Serum DLS

Facility

$155.00

Service Code	HCPCS 82746
Hospital Charge Code	422827465
Hospital Revenue Code	301
Min. Negotiated Rate	$131.75
Max. Negotiated Rate	$150.35
Rate for Payer: Cash Price	$100.75
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$139.50
Rate for Payer: MDX Hawaii PPO	$150.35

FOLEY CATH 30CC 14FR

Facility

$3.00

Hospital Charge Code	8111
Hospital Revenue Code	274
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Hawaii Western Management Group Commercial	$2.10
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
Rate for Payer: University Health Alliance Commercial	$1.68

FOLEY CATH 30CC 14FR

Facility

$3.00

Hospital Charge Code	8111
Hospital Revenue Code	274
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	$2.10
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	$1.68

FOLEY CATH 30CC 18 FR

Facility

$4.00

Hospital Charge Code	8112
Hospital Revenue Code	274
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Hawaii Western Management Group Commercial	$2.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.24

FOLEY CATH 30CC 18 FR

Facility

$4.00

Hospital Charge Code	8112
Hospital Revenue Code	274
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$2.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.24

FOLEY CATH 30CC 22 FR

Facility

$39.00

Hospital Charge Code	8113
Hospital Revenue Code	274
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$37.83
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$16.38
Rate for Payer: Cash Price	$25.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$35.88
Rate for Payer: Devoted Health Medicare	$16.38
Rate for Payer: Hawaii Medical Service Association Medicare	$16.38
Rate for Payer: Hawaii Western Management Group Commercial	$27.30
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Humana Medicare	$16.38
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicare	$16.38
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$16.38
Rate for Payer: UnitedHealthcare Medicare	$16.38
Rate for Payer: University Health Alliance Commercial	$21.84

FOLEY CATH 30CC 22 FR

Facility

$39.00

Hospital Charge Code	8113
Hospital Revenue Code	274
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$25.35
Rate for Payer: Hawaii Western Management Group Commercial	$27.30
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: University Health Alliance Commercial	$21.84

FOLEY CATH 30CC 24FR

Facility

$51.00

Hospital Charge Code	8114
Hospital Revenue Code	274
Min. Negotiated Rate	$28.56
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Hawaii Western Management Group Commercial	$35.70
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: University Health Alliance Commercial	$28.56

Know your out-of-pocket cost for care.

All Charges