Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

GLIDE SCOPE 2

Facility

$69.00

Hospital Charge Code	8129
Hospital Revenue Code	270
Min. Negotiated Rate	$28.98
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$50.29

GLIDE SCOPE 2

Facility

$69.00

Hospital Charge Code	8129
Hospital Revenue Code	270
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

GLIDE SCOPE 3

Facility

$86.00

Hospital Charge Code	8130
Hospital Revenue Code	270
Min. Negotiated Rate	$36.12
Max. Negotiated Rate	$83.42
Rate for Payer: AlohaCare Medicaid	$43.00
Rate for Payer: AlohaCare Medicare	$36.12
Rate for Payer: Cash Price	$55.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$79.12
Rate for Payer: Devoted Health Medicare	$36.12
Rate for Payer: Hawaii Medical Service Association Medicare	$36.12
Rate for Payer: Hawaii Western Management Group Commercial	$81.70
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Humana Medicare	$36.12
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: Kaiser Permanente Medicaid	$43.86
Rate for Payer: Kaiser Permanente Medicare	$36.12
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: Ohana Health Plan Medicaid	$36.12
Rate for Payer: Ohana Health Plan Medicare	$36.12
Rate for Payer: UnitedHealthcare Medicare	$36.12
Rate for Payer: University Health Alliance Commercial	$62.69

GLIDE SCOPE 3

Facility

$86.00

Hospital Charge Code	8130
Hospital Revenue Code	270
Min. Negotiated Rate	$73.10
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$55.90
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: MDX Hawaii PPO	$83.42

GLIDE SCOPE 4

Facility

$62.00

Hospital Charge Code	8131
Hospital Revenue Code	270
Min. Negotiated Rate	$26.04
Max. Negotiated Rate	$60.14
Rate for Payer: AlohaCare Medicaid	$31.00
Rate for Payer: AlohaCare Medicare	$26.04
Rate for Payer: Cash Price	$40.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$57.04
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Hawaii Medical Service Association Medicare	$26.04
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Humana Medicare	$26.04
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: Kaiser Permanente Medicare	$26.04
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$26.04
Rate for Payer: Ohana Health Plan Medicare	$26.04
Rate for Payer: UnitedHealthcare Medicare	$26.04
Rate for Payer: University Health Alliance Commercial	$45.19

GLIDE SCOPE 4

Facility

$62.00

Hospital Charge Code	8131
Hospital Revenue Code	270
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$40.30
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$55.80
Rate for Payer: MDX Hawaii PPO	$60.14

glimepiride 1 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 71921021401
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

glimepiride 1 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 71921021401
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

glimepiride 2 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00093725501
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

glimepiride 2 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00093725501
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

glimepiride 4 mg Tab [KMC]

Facility

$4.91

Service Code	NDC 71921021601
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$4.76
Rate for Payer: AlohaCare Medicaid	$2.46
Rate for Payer: AlohaCare Medicare	$2.06
Rate for Payer: Cash Price	$3.19
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.52
Rate for Payer: Devoted Health Medicare	$2.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.06
Rate for Payer: Hawaii Western Management Group Commercial	$4.66
Rate for Payer: Health Management Network Commercial	$4.17
Rate for Payer: Humana Medicare	$2.06
Rate for Payer: Kaiser Permanente Commercial	$4.42
Rate for Payer: Kaiser Permanente Medicaid	$2.50
Rate for Payer: Kaiser Permanente Medicare	$2.06
Rate for Payer: MDX Hawaii PPO	$4.76
Rate for Payer: Ohana Health Plan Medicaid	$2.06
Rate for Payer: Ohana Health Plan Medicare	$2.06
Rate for Payer: UnitedHealthcare Medicaid	$2.95
Rate for Payer: UnitedHealthcare Medicare	$2.06
Rate for Payer: University Health Alliance Commercial	$3.58

glimepiride 4 mg Tab [KMC]

Facility

$4.91

Service Code	NDC 71921021601
Hospital Revenue Code	250
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$4.76
Rate for Payer: Cash Price	$3.19
Rate for Payer: Health Management Network Commercial	$4.17
Rate for Payer: Kaiser Permanente Commercial	$4.42
Rate for Payer: MDX Hawaii PPO	$4.76

glipiZIDE 10 mg ER Tab [KMC]

Facility

$3.22

Service Code	NDC 16714089601
Hospital Revenue Code	250
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$3.12
Rate for Payer: AlohaCare Medicaid	$1.61
Rate for Payer: AlohaCare Medicare	$1.35
Rate for Payer: Cash Price	$2.09
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.96
Rate for Payer: Devoted Health Medicare	$1.35
Rate for Payer: Hawaii Medical Service Association Medicare	$1.35
Rate for Payer: Hawaii Western Management Group Commercial	$3.06
Rate for Payer: Health Management Network Commercial	$2.74
Rate for Payer: Humana Medicare	$1.35
Rate for Payer: Kaiser Permanente Commercial	$2.90
Rate for Payer: Kaiser Permanente Medicaid	$1.64
Rate for Payer: Kaiser Permanente Medicare	$1.35
Rate for Payer: MDX Hawaii PPO	$3.12
Rate for Payer: Ohana Health Plan Medicaid	$1.35
Rate for Payer: Ohana Health Plan Medicare	$1.35
Rate for Payer: UnitedHealthcare Medicaid	$1.93
Rate for Payer: UnitedHealthcare Medicare	$1.35
Rate for Payer: University Health Alliance Commercial	$2.35

glipiZIDE 10 mg ER Tab [KMC]

Facility

$3.22

Service Code	NDC 16714089601
Hospital Revenue Code	250
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.12
Rate for Payer: Cash Price	$2.09
Rate for Payer: Health Management Network Commercial	$2.74
Rate for Payer: Kaiser Permanente Commercial	$2.90
Rate for Payer: MDX Hawaii PPO	$3.12

glipiZIDE 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079081120
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

glipiZIDE 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079081120
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

glipiZIDE 2.5 mg ER [KMC]

Facility

$3.00

Service Code	NDC 64980027903
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

glipiZIDE 2.5 mg ER [KMC]

Facility

$3.00

Service Code	NDC 64980027903
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

glipiZIDE 5 mg ER [KMC]

Facility

$3.00

Service Code	NDC 16714089501
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

glipiZIDE 5 mg ER [KMC]

Facility

$3.00

Service Code	NDC 16714089501
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

glipiZIDE 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00591046001
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

glipiZIDE 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00591046001
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

glucagon recombinant 1 mg REC [KMC]

Facility

$777.60

Service Code	HCPCS J1610
Hospital Revenue Code	636
Min. Negotiated Rate	$660.96
Max. Negotiated Rate	$754.27
Rate for Payer: Cash Price	$505.44
Rate for Payer: Health Management Network Commercial	$660.96
Rate for Payer: Kaiser Permanente Commercial	$699.84
Rate for Payer: MDX Hawaii PPO	$754.27

glucagon recombinant 1 mg REC [KMC]

Facility

$777.60

Service Code	HCPCS J1610
Hospital Revenue Code	636
Min. Negotiated Rate	$182.91
Max. Negotiated Rate	$754.27
Rate for Payer: AlohaCare Medicaid	$388.80
Rate for Payer: AlohaCare Medicare	$326.59
Rate for Payer: Cash Price	$505.44
Rate for Payer: Cash Price	$505.44
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$715.39
Rate for Payer: Devoted Health Medicare	$326.59
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$195.79
Rate for Payer: Hawaii Medical Service Association Commercial	$182.91
Rate for Payer: Hawaii Medical Service Association Medicare	$326.59
Rate for Payer: Hawaii Western Management Group Commercial	$738.72
Rate for Payer: Health Management Network Commercial	$660.96
Rate for Payer: Humana Medicare	$326.59
Rate for Payer: Kaiser Permanente Commercial	$699.84
Rate for Payer: Kaiser Permanente Medicaid	$396.58
Rate for Payer: Kaiser Permanente Medicare	$326.59
Rate for Payer: MDX Hawaii PPO	$754.27
Rate for Payer: Ohana Health Plan Medicaid	$326.59
Rate for Payer: Ohana Health Plan Medicare	$326.59
Rate for Payer: UnitedHealthcare Medicaid	$466.56
Rate for Payer: UnitedHealthcare Medicare	$326.59
Rate for Payer: University Health Alliance Commercial	$566.79

Glucerna 237 mL liquid [KMC]

Facility

$12.88

Service Code	NDC 070074509051
Hospital Revenue Code	250
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$12.49
Rate for Payer: AlohaCare Medicaid	$6.44
Rate for Payer: AlohaCare Medicare	$5.41
Rate for Payer: Cash Price	$8.37
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.85
Rate for Payer: Devoted Health Medicare	$5.41
Rate for Payer: Hawaii Medical Service Association Medicare	$5.41
Rate for Payer: Hawaii Western Management Group Commercial	$12.24
Rate for Payer: Health Management Network Commercial	$10.95
Rate for Payer: Humana Medicare	$5.41
Rate for Payer: Kaiser Permanente Commercial	$11.59
Rate for Payer: Kaiser Permanente Medicaid	$6.57
Rate for Payer: Kaiser Permanente Medicare	$5.41
Rate for Payer: MDX Hawaii PPO	$12.49
Rate for Payer: Ohana Health Plan Medicaid	$5.41
Rate for Payer: Ohana Health Plan Medicare	$5.41
Rate for Payer: UnitedHealthcare Medicaid	$7.73
Rate for Payer: UnitedHealthcare Medicare	$5.41
Rate for Payer: University Health Alliance Commercial	$9.39

Know your out-of-pocket cost for care.

All Charges