Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

levocetirizine 5 mg Tab [KMC]

Facility

$12.31

Service Code	NDC 50228013630
Hospital Revenue Code	250
Min. Negotiated Rate	$10.46
Max. Negotiated Rate	$11.94
Rate for Payer: Cash Price	$8.00
Rate for Payer: Health Management Network Commercial	$10.46
Rate for Payer: Kaiser Permanente Commercial	$11.08
Rate for Payer: MDX Hawaii PPO	$11.94

levofloxacin 250 mg Tab [KMC]

Facility

$67.24

Service Code	NDC 65862053650
Hospital Revenue Code	250
Min. Negotiated Rate	$28.24
Max. Negotiated Rate	$65.22
Rate for Payer: AlohaCare Medicaid	$33.62
Rate for Payer: AlohaCare Medicare	$28.24
Rate for Payer: Cash Price	$43.71
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$61.86
Rate for Payer: Devoted Health Medicare	$28.24
Rate for Payer: Hawaii Medical Service Association Medicare	$28.24
Rate for Payer: Hawaii Western Management Group Commercial	$63.88
Rate for Payer: Health Management Network Commercial	$57.15
Rate for Payer: Humana Medicare	$28.24
Rate for Payer: Kaiser Permanente Commercial	$60.52
Rate for Payer: Kaiser Permanente Medicaid	$34.29
Rate for Payer: Kaiser Permanente Medicare	$28.24
Rate for Payer: MDX Hawaii PPO	$65.22
Rate for Payer: Ohana Health Plan Medicaid	$28.24
Rate for Payer: Ohana Health Plan Medicare	$28.24
Rate for Payer: UnitedHealthcare Medicaid	$40.34
Rate for Payer: UnitedHealthcare Medicare	$28.24
Rate for Payer: University Health Alliance Commercial	$49.01

levofloxacin 250 mg Tab [KMC]

Facility

$67.24

Service Code	NDC 65862053650
Hospital Revenue Code	250
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$65.22
Rate for Payer: Cash Price	$43.71
Rate for Payer: Health Management Network Commercial	$57.15
Rate for Payer: Kaiser Permanente Commercial	$60.52
Rate for Payer: MDX Hawaii PPO	$65.22

levoFLOXacin 500 mg/100 mL premixed bag [KMC]

Facility

$0.10

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: MDX Hawaii PPO	$0.10

levoFLOXacin 500 mg/100 mL premixed bag [KMC]

Facility

$0.10

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$1.96
Rate for Payer: AlohaCare Medicaid	$0.05
Rate for Payer: AlohaCare Medicare	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Medicare	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$0.10
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.10
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.06
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

levofloxacin 500 mg Tab [KMC]

Facility

$77.06

Service Code	NDC 65862053750
Hospital Revenue Code	250
Min. Negotiated Rate	$65.50
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$50.09
Rate for Payer: Health Management Network Commercial	$65.50
Rate for Payer: Kaiser Permanente Commercial	$69.35
Rate for Payer: MDX Hawaii PPO	$74.75

levofloxacin 500 mg Tab [KMC]

Facility

$77.06

Service Code	NDC 65862053750
Hospital Revenue Code	250
Min. Negotiated Rate	$32.37
Max. Negotiated Rate	$74.75
Rate for Payer: AlohaCare Medicaid	$38.53
Rate for Payer: AlohaCare Medicare	$32.37
Rate for Payer: Cash Price	$50.09
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$70.90
Rate for Payer: Devoted Health Medicare	$32.37
Rate for Payer: Hawaii Medical Service Association Medicare	$32.37
Rate for Payer: Hawaii Western Management Group Commercial	$73.21
Rate for Payer: Health Management Network Commercial	$65.50
Rate for Payer: Humana Medicare	$32.37
Rate for Payer: Kaiser Permanente Commercial	$69.35
Rate for Payer: Kaiser Permanente Medicaid	$39.30
Rate for Payer: Kaiser Permanente Medicare	$32.37
Rate for Payer: MDX Hawaii PPO	$74.75
Rate for Payer: Ohana Health Plan Medicaid	$32.37
Rate for Payer: Ohana Health Plan Medicare	$32.37
Rate for Payer: UnitedHealthcare Medicaid	$46.24
Rate for Payer: UnitedHealthcare Medicare	$32.37
Rate for Payer: University Health Alliance Commercial	$56.17

levofloxacin 750 mg/150 mL IV Sol [KMC]

Facility

$0.35

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Management Network Commercial	$0.30
Rate for Payer: Kaiser Permanente Commercial	$0.32
Rate for Payer: MDX Hawaii PPO	$0.34

levofloxacin 750 mg/150 mL IV Sol [KMC]

Facility

$0.35

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$1.96
Rate for Payer: AlohaCare Medicaid	$0.18
Rate for Payer: AlohaCare Medicare	$0.15
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.23
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.32
Rate for Payer: Devoted Health Medicare	$0.15
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Medicare	$0.15
Rate for Payer: Hawaii Western Management Group Commercial	$0.33
Rate for Payer: Health Management Network Commercial	$0.30
Rate for Payer: Humana Medicare	$0.15
Rate for Payer: Kaiser Permanente Commercial	$0.32
Rate for Payer: Kaiser Permanente Medicaid	$0.18
Rate for Payer: Kaiser Permanente Medicare	$0.15
Rate for Payer: MDX Hawaii PPO	$0.34
Rate for Payer: Ohana Health Plan Medicaid	$0.15
Rate for Payer: Ohana Health Plan Medicare	$0.15
Rate for Payer: UnitedHealthcare Medicaid	$0.21
Rate for Payer: UnitedHealthcare Medicare	$0.15
Rate for Payer: University Health Alliance Commercial	$0.26

levoFLOXacin 750 mg Tab [KMC]

Facility

$98.45

Service Code	NDC 00904635361
Hospital Revenue Code	250
Min. Negotiated Rate	$41.35
Max. Negotiated Rate	$95.50
Rate for Payer: AlohaCare Medicaid	$49.23
Rate for Payer: AlohaCare Medicare	$41.35
Rate for Payer: Cash Price	$63.99
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$90.57
Rate for Payer: Devoted Health Medicare	$41.35
Rate for Payer: Hawaii Medical Service Association Medicare	$41.35
Rate for Payer: Hawaii Western Management Group Commercial	$93.53
Rate for Payer: Health Management Network Commercial	$83.68
Rate for Payer: Humana Medicare	$41.35
Rate for Payer: Kaiser Permanente Commercial	$88.61
Rate for Payer: Kaiser Permanente Medicaid	$50.21
Rate for Payer: Kaiser Permanente Medicare	$41.35
Rate for Payer: MDX Hawaii PPO	$95.50
Rate for Payer: Ohana Health Plan Medicaid	$41.35
Rate for Payer: Ohana Health Plan Medicare	$41.35
Rate for Payer: UnitedHealthcare Medicaid	$59.07
Rate for Payer: UnitedHealthcare Medicare	$41.35
Rate for Payer: University Health Alliance Commercial	$71.76

levoFLOXacin 750 mg Tab [KMC]

Facility

$98.45

Service Code	NDC 00904635361
Hospital Revenue Code	250
Min. Negotiated Rate	$83.68
Max. Negotiated Rate	$95.50
Rate for Payer: Cash Price	$63.99
Rate for Payer: Health Management Network Commercial	$83.68
Rate for Payer: Kaiser Permanente Commercial	$88.61
Rate for Payer: MDX Hawaii PPO	$95.50

levonorgestrel 1.5 mg Tab [KMC]

Facility

$146.65

Service Code	NDC 52544028754
Hospital Revenue Code	250
Min. Negotiated Rate	$61.59
Max. Negotiated Rate	$142.25
Rate for Payer: AlohaCare Medicaid	$73.33
Rate for Payer: AlohaCare Medicare	$61.59
Rate for Payer: Cash Price	$95.32
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$134.92
Rate for Payer: Devoted Health Medicare	$61.59
Rate for Payer: Hawaii Medical Service Association Medicare	$61.59
Rate for Payer: Hawaii Western Management Group Commercial	$139.32
Rate for Payer: Health Management Network Commercial	$124.65
Rate for Payer: Humana Medicare	$61.59
Rate for Payer: Kaiser Permanente Commercial	$131.99
Rate for Payer: Kaiser Permanente Medicaid	$74.79
Rate for Payer: Kaiser Permanente Medicare	$61.59
Rate for Payer: MDX Hawaii PPO	$142.25
Rate for Payer: Ohana Health Plan Medicaid	$61.59
Rate for Payer: Ohana Health Plan Medicare	$61.59
Rate for Payer: UnitedHealthcare Medicaid	$87.99
Rate for Payer: UnitedHealthcare Medicare	$61.59
Rate for Payer: University Health Alliance Commercial	$106.89

levonorgestrel 1.5 mg Tab [KMC]

Facility

$146.65

Service Code	NDC 52544028754
Hospital Revenue Code	250
Min. Negotiated Rate	$124.65
Max. Negotiated Rate	$142.25
Rate for Payer: Cash Price	$95.32
Rate for Payer: Health Management Network Commercial	$124.65
Rate for Payer: Kaiser Permanente Commercial	$131.99
Rate for Payer: MDX Hawaii PPO	$142.25

levothyroxine 100 mcg (0.1 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 00527328446
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

levothyroxine 100 mcg (0.1 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 00527328446
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

levothyroxine 100 mcg / 5 mL IV Soln [KMC]

Facility

$85.14

Service Code	HCPCS J0650
Hospital Revenue Code	636
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$82.59
Rate for Payer: Cash Price	$55.34
Rate for Payer: Health Management Network Commercial	$72.37
Rate for Payer: Kaiser Permanente Commercial	$76.63
Rate for Payer: MDX Hawaii PPO	$82.59

levothyroxine 100 mcg / 5 mL IV Soln [KMC]

Facility

$85.14

Service Code	HCPCS J0650
Hospital Revenue Code	636
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$82.59
Rate for Payer: AlohaCare Medicaid	$42.57
Rate for Payer: AlohaCare Medicare	$35.76
Rate for Payer: Cash Price	$55.34
Rate for Payer: Cash Price	$55.34
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$78.33
Rate for Payer: Devoted Health Medicare	$35.76
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.70
Rate for Payer: Hawaii Medical Service Association Medicare	$35.76
Rate for Payer: Hawaii Western Management Group Commercial	$80.88
Rate for Payer: Health Management Network Commercial	$72.37
Rate for Payer: Humana Medicare	$35.76
Rate for Payer: Kaiser Permanente Commercial	$76.63
Rate for Payer: Kaiser Permanente Medicaid	$43.42
Rate for Payer: Kaiser Permanente Medicare	$35.76
Rate for Payer: MDX Hawaii PPO	$82.59
Rate for Payer: Ohana Health Plan Medicaid	$35.76
Rate for Payer: Ohana Health Plan Medicare	$35.76
Rate for Payer: UnitedHealthcare Medicaid	$51.08
Rate for Payer: UnitedHealthcare Medicare	$35.76
Rate for Payer: University Health Alliance Commercial	$62.06

levothyroxine 112 mcg (0.112 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 16729045215
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

levothyroxine 112 mcg (0.112 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 16729045215
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

levothyroxine 125 mcg (0.125 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305012530
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

levothyroxine 125 mcg (0.125 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305012530
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

levothyroxine 137 mcg (0.137 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305013730
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

levothyroxine 137 mcg (0.137 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305013730
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

levothyroxine 50 mcg (0.05 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305005030
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

levothyroxine 50 mcg (0.05 mg) Tab [KMC]

Facility

$3.00

Service Code	NDC 72305005030
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

Know your out-of-pocket cost for care.

All Charges