Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

hydroxychloroquine 200 mg Tab [KMC]

Facility

$16.74

Service Code	NDC 16714011001
Hospital Revenue Code	250
Min. Negotiated Rate	$7.03
Max. Negotiated Rate	$16.24
Rate for Payer: AlohaCare Medicaid	$8.37
Rate for Payer: AlohaCare Medicare	$7.03
Rate for Payer: Cash Price	$10.88
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.40
Rate for Payer: Devoted Health Medicare	$7.03
Rate for Payer: Hawaii Medical Service Association Medicare	$7.03
Rate for Payer: Hawaii Western Management Group Commercial	$15.90
Rate for Payer: Health Management Network Commercial	$14.23
Rate for Payer: Humana Medicare	$7.03
Rate for Payer: Kaiser Permanente Commercial	$15.07
Rate for Payer: Kaiser Permanente Medicaid	$8.54
Rate for Payer: Kaiser Permanente Medicare	$7.03
Rate for Payer: MDX Hawaii PPO	$16.24
Rate for Payer: Ohana Health Plan Medicaid	$7.03
Rate for Payer: Ohana Health Plan Medicare	$7.03
Rate for Payer: UnitedHealthcare Medicaid	$10.04
Rate for Payer: UnitedHealthcare Medicare	$7.03
Rate for Payer: University Health Alliance Commercial	$12.20

hydroxyurea 500 mg Cap [KMC]

Facility

$5.11

Service Code	HCPCS S0176
Hospital Revenue Code	637
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$4.96
Rate for Payer: Cash Price	$3.32
Rate for Payer: Health Management Network Commercial	$4.34
Rate for Payer: Kaiser Permanente Commercial	$4.60
Rate for Payer: MDX Hawaii PPO	$4.96

hydroxyurea 500 mg Cap [KMC]

Facility

$5.11

Service Code	HCPCS S0176
Hospital Revenue Code	637
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$4.96
Rate for Payer: AlohaCare Medicaid	$2.56
Rate for Payer: AlohaCare Medicare	$2.15
Rate for Payer: Cash Price	$3.32
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.70
Rate for Payer: Devoted Health Medicare	$2.15
Rate for Payer: Hawaii Medical Service Association Medicare	$2.15
Rate for Payer: Hawaii Western Management Group Commercial	$4.85
Rate for Payer: Health Management Network Commercial	$4.34
Rate for Payer: Humana Medicare	$2.15
Rate for Payer: Kaiser Permanente Commercial	$4.60
Rate for Payer: Kaiser Permanente Medicaid	$2.61
Rate for Payer: Kaiser Permanente Medicare	$2.15
Rate for Payer: MDX Hawaii PPO	$4.96
Rate for Payer: Ohana Health Plan Medicaid	$2.15
Rate for Payer: Ohana Health Plan Medicare	$2.15
Rate for Payer: UnitedHealthcare Medicare	$2.15
Rate for Payer: University Health Alliance Commercial	$3.72

hydrOXYzine 25 mg Cap [KMC]

Facility

$3.00

Service Code	HCPCS Q0177
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

hydrOXYzine 25 mg Cap [KMC]

Facility

$3.00

Service Code	HCPCS Q0177
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

hydrOXYzine hydrochloride 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 16714008104
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

hydrOXYzine hydrochloride 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 16714008104
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

hyoscyamine 0.125 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 70156010401
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

hyoscyamine 0.125 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 70156010401
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

HYPERTENSION WITH MCC

Facility

$13,699.76

Service Code	MSDRG 304
Min. Negotiated Rate	$13,699.76
Max. Negotiated Rate	$13,699.76
Rate for Payer: Hawaii Medical Service Association Commercial	$13,699.76

HYPERTENSION WITHOUT MCC

Facility

$13,699.76

Service Code	MSDRG 305
Min. Negotiated Rate	$13,699.76
Max. Negotiated Rate	$13,699.76
Rate for Payer: Hawaii Medical Service Association Commercial	$13,699.76

HZV ZOSTER VACC RECOMBINANT ADJUVANTED IM USE

Professional

Both

$224.00

Service Code	HCPCS 90750
Hospital Revenue Code	636
Min. Negotiated Rate	$163.52
Max. Negotiated Rate	$190.40
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cash Price	$145.60
Rate for Payer: Hawaii Western Management Group Commercial	$163.52
Rate for Payer: Health Management Network Commercial	$190.40

IAADIADOO INFLUENZA

Professional

Both

$52.00

Service Code	HCPCS 87804
Hospital Revenue Code	300
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$44.20
Rate for Payer: AlohaCare Medicaid	$16.58
Rate for Payer: AlohaCare Medicare	$16.55
Rate for Payer: Cash Price	$33.80
Rate for Payer: Cash Price	$33.80
Rate for Payer: Devoted Health Medicare	$16.55
Rate for Payer: Hawaii Medical Service Association Medicare	$16.55
Rate for Payer: Hawaii Western Management Group Commercial	$16.58
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Kaiser Permanente Commercial	$19.86
Rate for Payer: Kaiser Permanente Medicaid	$19.86
Rate for Payer: Kaiser Permanente Medicare	$19.86
Rate for Payer: Ohana Health Plan Medicaid	$16.58
Rate for Payer: Ohana Health Plan Medicare	$16.55
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$16.55

IAADIADOO RESPIRATORY SYNCTIAL VIRUS

Professional

Both

$40.00

Service Code	HCPCS 87807
Hospital Revenue Code	300
Min. Negotiated Rate	$13.10
Max. Negotiated Rate	$34.00
Rate for Payer: AlohaCare Medicaid	$16.58
Rate for Payer: AlohaCare Medicare	$13.10
Rate for Payer: Cash Price	$26.00
Rate for Payer: Cash Price	$26.00
Rate for Payer: Devoted Health Medicare	$13.10
Rate for Payer: Hawaii Medical Service Association Medicare	$13.10
Rate for Payer: Hawaii Western Management Group Commercial	$16.75
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$15.72
Rate for Payer: Kaiser Permanente Medicaid	$15.72
Rate for Payer: Kaiser Permanente Medicare	$15.72
Rate for Payer: Ohana Health Plan Medicaid	$16.58
Rate for Payer: Ohana Health Plan Medicare	$13.10
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$13.10

IAADIADOO STREPTOCOCCUS GROUP A

Professional

Both

$29.00

Service Code	HCPCS 87880
Hospital Revenue Code	300
Min. Negotiated Rate	$16.53
Max. Negotiated Rate	$24.65
Rate for Payer: AlohaCare Medicaid	$16.58
Rate for Payer: AlohaCare Medicare	$16.53
Rate for Payer: Cash Price	$18.85
Rate for Payer: Cash Price	$18.85
Rate for Payer: Devoted Health Medicare	$16.53
Rate for Payer: Hawaii Medical Service Association Medicare	$16.53
Rate for Payer: Hawaii Western Management Group Commercial	$19.08
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$19.84
Rate for Payer: Kaiser Permanente Medicaid	$19.84
Rate for Payer: Kaiser Permanente Medicare	$19.84
Rate for Payer: Ohana Health Plan Medicaid	$16.58
Rate for Payer: Ohana Health Plan Medicare	$16.53
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$16.53

IADNA DNA/RNA RSV AMPLIFIED PROBE TECHNIQUE

Professional

Both

$51.00

Service Code	HCPCS 87634
Hospital Revenue Code	300
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$86.65
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$70.20
Rate for Payer: Cash Price	$33.15
Rate for Payer: Cash Price	$33.15
Rate for Payer: Devoted Health Medicare	$70.20
Rate for Payer: Hawaii Medical Service Association Medicare	$70.20
Rate for Payer: Hawaii Western Management Group Commercial	$86.65
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$84.24
Rate for Payer: Kaiser Permanente Medicaid	$84.24
Rate for Payer: Kaiser Permanente Medicare	$84.24
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$70.20
Rate for Payer: UnitedHealthcare Medicaid	$52.00
Rate for Payer: UnitedHealthcare Medicare	$70.20

IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ

Professional

Both

$292.00

Service Code	HCPCS 87635
Hospital Revenue Code	300
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$248.20
Rate for Payer: AlohaCare Medicaid	$51.31
Rate for Payer: AlohaCare Medicare	$51.31
Rate for Payer: Cash Price	$189.80
Rate for Payer: Cash Price	$189.80
Rate for Payer: Devoted Health Medicare	$51.31
Rate for Payer: Hawaii Medical Service Association Medicare	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.33
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: Kaiser Permanente Commercial	$61.57
Rate for Payer: Kaiser Permanente Medicaid	$61.57
Rate for Payer: Kaiser Permanente Medicare	$61.57
Rate for Payer: Ohana Health Plan Medicaid	$51.31
Rate for Payer: Ohana Health Plan Medicare	$51.31
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$51.31

IADNA STREPTOCOCCUS GROUP B AMPLIFIED PROBE TQ

Professional

Both

$328.00

Service Code	HCPCS 87653
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$278.80
Rate for Payer: AlohaCare Medicaid	$49.04
Rate for Payer: AlohaCare Medicare	$35.09
Rate for Payer: Cash Price	$213.20
Rate for Payer: Cash Price	$213.20
Rate for Payer: Devoted Health Medicare	$35.09
Rate for Payer: Hawaii Medical Service Association Medicare	$35.09
Rate for Payer: Hawaii Western Management Group Commercial	$49.05
Rate for Payer: Health Management Network Commercial	$278.80
Rate for Payer: Kaiser Permanente Commercial	$42.11
Rate for Payer: Kaiser Permanente Medicaid	$42.11
Rate for Payer: Kaiser Permanente Medicare	$42.11
Rate for Payer: Ohana Health Plan Medicaid	$49.04
Rate for Payer: Ohana Health Plan Medicare	$35.09
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$35.09

ibandronate 150 mg Tab [KMC]

Facility

$554.91

Service Code	NDC 55111057503
Hospital Revenue Code	250
Min. Negotiated Rate	$471.67
Max. Negotiated Rate	$538.26
Rate for Payer: Cash Price	$360.69
Rate for Payer: Health Management Network Commercial	$471.67
Rate for Payer: Kaiser Permanente Commercial	$499.42
Rate for Payer: MDX Hawaii PPO	$538.26

ibandronate 150 mg Tab [KMC]

Facility

$554.91

Service Code	NDC 55111057503
Hospital Revenue Code	250
Min. Negotiated Rate	$233.06
Max. Negotiated Rate	$538.26
Rate for Payer: AlohaCare Medicaid	$277.45
Rate for Payer: AlohaCare Medicare	$233.06
Rate for Payer: Cash Price	$360.69
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$510.52
Rate for Payer: Devoted Health Medicare	$233.06
Rate for Payer: Hawaii Medical Service Association Medicare	$233.06
Rate for Payer: Hawaii Western Management Group Commercial	$527.16
Rate for Payer: Health Management Network Commercial	$471.67
Rate for Payer: Humana Medicare	$233.06
Rate for Payer: Kaiser Permanente Commercial	$499.42
Rate for Payer: Kaiser Permanente Medicaid	$283.00
Rate for Payer: Kaiser Permanente Medicare	$233.06
Rate for Payer: MDX Hawaii PPO	$538.26
Rate for Payer: Ohana Health Plan Medicaid	$233.06
Rate for Payer: Ohana Health Plan Medicare	$233.06
Rate for Payer: UnitedHealthcare Medicaid	$332.95
Rate for Payer: UnitedHealthcare Medicare	$233.06
Rate for Payer: University Health Alliance Commercial	$404.47

ibuprofen 100 mg/5 mL Oral Susp [KMC]

Facility

$0.16

Service Code	NDC 45802013326
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Management Network Commercial	$0.14
Rate for Payer: Kaiser Permanente Commercial	$0.14
Rate for Payer: MDX Hawaii PPO	$0.16

ibuprofen 100 mg/5 mL Oral Susp [KMC]

Facility

$0.16

Service Code	NDC 45802013326
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: AlohaCare Medicaid	$0.08
Rate for Payer: AlohaCare Medicare	$0.07
Rate for Payer: Cash Price	$0.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.15
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	$0.15
Rate for Payer: Health Management Network Commercial	$0.14
Rate for Payer: Humana Medicare	$0.07
Rate for Payer: Kaiser Permanente Commercial	$0.14
Rate for Payer: Kaiser Permanente Medicaid	$0.08
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

ibuprofen 200 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 70677113603
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

ibuprofen 200 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 70677113603
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

ibuprofen 400 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 65162046410
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

Know your out-of-pocket cost for care.

All Charges