Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

H.Pylori-Stool DLS

Facility

$224.00

Service Code	HCPCS 87338
Hospital Charge Code	422873385
Hospital Revenue Code	306
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$217.28
Rate for Payer: AlohaCare Medicaid	$112.00
Rate for Payer: AlohaCare Medicare	$94.08
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cash Price	$145.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$206.08
Rate for Payer: Devoted Health Medicare	$94.08
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$17.98
Rate for Payer: Hawaii Medical Service Association Medicare	$94.08
Rate for Payer: Hawaii Western Management Group Commercial	$14.38
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Humana Medicare	$94.08
Rate for Payer: Kaiser Permanente Commercial	$201.60
Rate for Payer: Kaiser Permanente Medicaid	$114.24
Rate for Payer: Kaiser Permanente Medicare	$94.08
Rate for Payer: MDX Hawaii PPO	$217.28
Rate for Payer: Ohana Health Plan Medicaid	$94.08
Rate for Payer: Ohana Health Plan Medicare	$94.08
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$94.08
Rate for Payer: University Health Alliance Commercial	$31.01

HSV 1/2 Ab, IgM, Reflex to Titer DLS

Facility

$89.00

Service Code	HCPCS 86695
Hospital Charge Code	422866955
Hospital Revenue Code	301
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$37.38
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$81.88
Rate for Payer: Devoted Health Medicare	$37.38
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.23
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$37.38
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$37.38
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$37.38
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$37.38
Rate for Payer: Ohana Health Plan Medicare	$37.38
Rate for Payer: UnitedHealthcare Medicaid	$18.23
Rate for Payer: UnitedHealthcare Medicare	$37.38
Rate for Payer: University Health Alliance Commercial	$34.10

HSV 1/2 Ab, IgM, Reflex to Titer DLS

Facility

$89.00

Service Code	HCPCS 86695
Hospital Charge Code	422866955
Hospital Revenue Code	301
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

HUMERUS MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73060
Hospital Charge Code	424730600
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

HUMERUS MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73060
Hospital Charge Code	424730600
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
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	$18.84
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	$18.84
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$61.20

Hx Check

Facility

$129.00

Service Code	HCPCS 86901
Hospital Charge Code	422869010
Hospital Revenue Code	302
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

Hx Check

Facility

$129.00

Service Code	HCPCS 86901
Hospital Charge Code	422869010
Hospital Revenue Code	302
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$54.18
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.68
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.22
Rate for Payer: Hawaii Medical Service Association Commercial	$3.74
Rate for Payer: Hawaii Medical Service Association Medicare	$54.18
Rate for Payer: Hawaii Western Management Group Commercial	$2.99
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$54.18
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$54.18
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$54.18
Rate for Payer: Ohana Health Plan Medicare	$54.18
Rate for Payer: UnitedHealthcare Medicaid	$8.22
Rate for Payer: UnitedHealthcare Medicare	$54.18
Rate for Payer: University Health Alliance Commercial	$7.71

hyaluronidase 150 units/mL Soln [KMC]

Facility

$267.84

Service Code	HCPCS J3473
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$259.80
Rate for Payer: AlohaCare Medicaid	$133.92
Rate for Payer: AlohaCare Medicare	$112.49
Rate for Payer: Cash Price	$174.10
Rate for Payer: Cash Price	$174.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$246.41
Rate for Payer: Devoted Health Medicare	$112.49
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.36
Rate for Payer: Hawaii Medical Service Association Medicare	$112.49
Rate for Payer: Hawaii Western Management Group Commercial	$254.45
Rate for Payer: Health Management Network Commercial	$227.66
Rate for Payer: Humana Medicare	$112.49
Rate for Payer: Kaiser Permanente Commercial	$241.06
Rate for Payer: Kaiser Permanente Medicaid	$136.60
Rate for Payer: Kaiser Permanente Medicare	$112.49
Rate for Payer: MDX Hawaii PPO	$259.80
Rate for Payer: Ohana Health Plan Medicaid	$112.49
Rate for Payer: Ohana Health Plan Medicare	$112.49
Rate for Payer: UnitedHealthcare Medicaid	$160.70
Rate for Payer: UnitedHealthcare Medicare	$112.49
Rate for Payer: University Health Alliance Commercial	$195.23

hyaluronidase 150 units/mL Soln [KMC]

Facility

$267.84

Service Code	HCPCS J3473
Hospital Revenue Code	636
Min. Negotiated Rate	$227.66
Max. Negotiated Rate	$259.80
Rate for Payer: Cash Price	$174.10
Rate for Payer: Health Management Network Commercial	$227.66
Rate for Payer: Kaiser Permanente Commercial	$241.06
Rate for Payer: MDX Hawaii PPO	$259.80

hydrALAZINE 100 mg Tab [KMC]

Facility

$4.05

Service Code	NDC 23155083501
Hospital Revenue Code	250
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$3.93
Rate for Payer: Cash Price	$2.63
Rate for Payer: Health Management Network Commercial	$3.44
Rate for Payer: Kaiser Permanente Commercial	$3.65
Rate for Payer: MDX Hawaii PPO	$3.93

hydrALAZINE 100 mg Tab [KMC]

Facility

$4.05

Service Code	NDC 23155083501
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$3.93
Rate for Payer: AlohaCare Medicaid	$2.02
Rate for Payer: AlohaCare Medicare	$1.70
Rate for Payer: Cash Price	$2.63
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.73
Rate for Payer: Devoted Health Medicare	$1.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1.70
Rate for Payer: Hawaii Western Management Group Commercial	$3.85
Rate for Payer: Health Management Network Commercial	$3.44
Rate for Payer: Humana Medicare	$1.70
Rate for Payer: Kaiser Permanente Commercial	$3.65
Rate for Payer: Kaiser Permanente Medicaid	$2.07
Rate for Payer: Kaiser Permanente Medicare	$1.70
Rate for Payer: MDX Hawaii PPO	$3.93
Rate for Payer: Ohana Health Plan Medicaid	$1.70
Rate for Payer: Ohana Health Plan Medicare	$1.70
Rate for Payer: UnitedHealthcare Medicaid	$2.43
Rate for Payer: UnitedHealthcare Medicare	$1.70
Rate for Payer: University Health Alliance Commercial	$2.95

hydrALAZINE 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 23155083201
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

hydrALAZINE 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 23155083201
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

hydrALAZINE 20 mg/mL Inj Sol [KMC]

Facility

$57.60

Service Code	HCPCS J0360
Hospital Revenue Code	636
Min. Negotiated Rate	$5.19
Max. Negotiated Rate	$55.87
Rate for Payer: AlohaCare Medicaid	$28.80
Rate for Payer: AlohaCare Medicare	$24.19
Rate for Payer: Cash Price	$37.44
Rate for Payer: Cash Price	$37.44
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$52.99
Rate for Payer: Devoted Health Medicare	$24.19
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$5.19
Rate for Payer: Hawaii Medical Service Association Medicare	$24.19
Rate for Payer: Hawaii Western Management Group Commercial	$54.72
Rate for Payer: Health Management Network Commercial	$48.96
Rate for Payer: Humana Medicare	$24.19
Rate for Payer: Kaiser Permanente Commercial	$51.84
Rate for Payer: Kaiser Permanente Medicaid	$29.38
Rate for Payer: Kaiser Permanente Medicare	$24.19
Rate for Payer: MDX Hawaii PPO	$55.87
Rate for Payer: Ohana Health Plan Medicaid	$24.19
Rate for Payer: Ohana Health Plan Medicare	$24.19
Rate for Payer: UnitedHealthcare Medicaid	$34.56
Rate for Payer: UnitedHealthcare Medicare	$24.19
Rate for Payer: University Health Alliance Commercial	$41.98

hydrALAZINE 20 mg/mL Inj Sol [KMC]

Facility

$57.60

Service Code	HCPCS J0360
Hospital Revenue Code	636
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$55.87
Rate for Payer: Cash Price	$37.44
Rate for Payer: Health Management Network Commercial	$48.96
Rate for Payer: Kaiser Permanente Commercial	$51.84
Rate for Payer: MDX Hawaii PPO	$55.87

hydrALAZINE 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 23155083301
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

hydrALAZINE 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 23155083301
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

hydrochlorothiazide 12.5 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 29300013001
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

hydrochlorothiazide 12.5 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 29300013001
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

hydrochlorothiazide 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 43547039710
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

hydrochlorothiazide 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 43547039710
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

hydrocortisone 100 mg / 2 mL REC vial [KMC]

Facility

$102.80

Service Code	HCPCS J1720
Hospital Revenue Code	636
Min. Negotiated Rate	$87.38
Max. Negotiated Rate	$99.72
Rate for Payer: Cash Price	$66.82
Rate for Payer: Health Management Network Commercial	$87.38
Rate for Payer: Kaiser Permanente Commercial	$92.52
Rate for Payer: MDX Hawaii PPO	$99.72

hydrocortisone 100 mg / 2 mL REC vial [KMC]

Facility

$102.80

Service Code	HCPCS J1720
Hospital Revenue Code	636
Min. Negotiated Rate	$21.20
Max. Negotiated Rate	$99.72
Rate for Payer: AlohaCare Medicaid	$51.40
Rate for Payer: AlohaCare Medicare	$43.18
Rate for Payer: Cash Price	$66.82
Rate for Payer: Cash Price	$66.82
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$94.58
Rate for Payer: Devoted Health Medicare	$43.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$21.20
Rate for Payer: Hawaii Medical Service Association Medicare	$43.18
Rate for Payer: Hawaii Western Management Group Commercial	$97.66
Rate for Payer: Health Management Network Commercial	$87.38
Rate for Payer: Humana Medicare	$43.18
Rate for Payer: Kaiser Permanente Commercial	$92.52
Rate for Payer: Kaiser Permanente Medicaid	$52.43
Rate for Payer: Kaiser Permanente Medicare	$43.18
Rate for Payer: MDX Hawaii PPO	$99.72
Rate for Payer: Ohana Health Plan Medicaid	$43.18
Rate for Payer: Ohana Health Plan Medicare	$43.18
Rate for Payer: UnitedHealthcare Medicaid	$61.68
Rate for Payer: UnitedHealthcare Medicare	$43.18
Rate for Payer: University Health Alliance Commercial	$74.93

hydrocortisone 10 mg Tab [KMC]

Facility

$6.88

Service Code	NDC 64380097106
Hospital Revenue Code	250
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$6.67
Rate for Payer: AlohaCare Medicaid	$3.44
Rate for Payer: AlohaCare Medicare	$2.89
Rate for Payer: Cash Price	$4.47
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.33
Rate for Payer: Devoted Health Medicare	$2.89
Rate for Payer: Hawaii Medical Service Association Medicare	$2.89
Rate for Payer: Hawaii Western Management Group Commercial	$6.54
Rate for Payer: Health Management Network Commercial	$5.85
Rate for Payer: Humana Medicare	$2.89
Rate for Payer: Kaiser Permanente Commercial	$6.19
Rate for Payer: Kaiser Permanente Medicaid	$3.51
Rate for Payer: Kaiser Permanente Medicare	$2.89
Rate for Payer: MDX Hawaii PPO	$6.67
Rate for Payer: Ohana Health Plan Medicaid	$2.89
Rate for Payer: Ohana Health Plan Medicare	$2.89
Rate for Payer: UnitedHealthcare Medicaid	$4.13
Rate for Payer: UnitedHealthcare Medicare	$2.89
Rate for Payer: University Health Alliance Commercial	$5.01

hydrocortisone 10 mg Tab [KMC]

Facility

$6.88

Service Code	NDC 64380097106
Hospital Revenue Code	250
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$6.67
Rate for Payer: Cash Price	$4.47
Rate for Payer: Health Management Network Commercial	$5.85
Rate for Payer: Kaiser Permanente Commercial	$6.19
Rate for Payer: MDX Hawaii PPO	$6.67

Know your out-of-pocket cost for care.

All Charges