Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

allopurinol 300 mg Tab [KMC]

Facility

$3.69

Service Code	NDC 16714057701
Hospital Revenue Code	250
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$3.58
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.14
Rate for Payer: Kaiser Permanente Commercial	$3.32
Rate for Payer: MDX Hawaii PPO	$3.58

alogliptin 25 mg Tab [KMC]

Facility

$31.20

Service Code	NDC 45802015065
Hospital Revenue Code	250
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$30.26
Rate for Payer: Cash Price	$20.28
Rate for Payer: Health Management Network Commercial	$26.52
Rate for Payer: Kaiser Permanente Commercial	$28.08
Rate for Payer: MDX Hawaii PPO	$30.26

alogliptin 25 mg Tab [KMC]

Facility

$31.20

Service Code	NDC 45802015065
Hospital Revenue Code	250
Min. Negotiated Rate	$13.10
Max. Negotiated Rate	$30.26
Rate for Payer: AlohaCare Medicaid	$15.60
Rate for Payer: AlohaCare Medicare	$13.10
Rate for Payer: Cash Price	$20.28
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$28.70
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	$29.64
Rate for Payer: Health Management Network Commercial	$26.52
Rate for Payer: Humana Medicare	$13.10
Rate for Payer: Kaiser Permanente Commercial	$28.08
Rate for Payer: Kaiser Permanente Medicaid	$15.91
Rate for Payer: Kaiser Permanente Medicare	$13.10
Rate for Payer: MDX Hawaii PPO	$30.26
Rate for Payer: Ohana Health Plan Medicaid	$13.10
Rate for Payer: Ohana Health Plan Medicare	$13.10
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$13.10
Rate for Payer: University Health Alliance Commercial	$22.74

AlOH - MgOH - simethicone 2400-2400-240 mg / 30 mL Susp [KMC]

Facility

$0.50

Service Code	NDC 00121176230
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.49
Rate for Payer: AlohaCare Medicaid	$0.25
Rate for Payer: AlohaCare Medicare	$0.21
Rate for Payer: Cash Price	$0.32
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.46
Rate for Payer: Devoted Health Medicare	$0.21
Rate for Payer: Hawaii Medical Service Association Medicare	$0.21
Rate for Payer: Hawaii Western Management Group Commercial	$0.48
Rate for Payer: Health Management Network Commercial	$0.43
Rate for Payer: Humana Medicare	$0.21
Rate for Payer: Kaiser Permanente Commercial	$0.45
Rate for Payer: Kaiser Permanente Medicaid	$0.26
Rate for Payer: Kaiser Permanente Medicare	$0.21
Rate for Payer: MDX Hawaii PPO	$0.49
Rate for Payer: Ohana Health Plan Medicaid	$0.21
Rate for Payer: Ohana Health Plan Medicare	$0.21
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: UnitedHealthcare Medicare	$0.21
Rate for Payer: University Health Alliance Commercial	$0.36

AlOH - MgOH - simethicone 2400-2400-240 mg / 30 mL Susp [KMC]

Facility

$0.50

Service Code	NDC 00121176230
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Management Network Commercial	$0.43
Rate for Payer: Kaiser Permanente Commercial	$0.45
Rate for Payer: MDX Hawaii PPO	$0.49

Alpha1-Antitrypsin DLS

Facility

$192.00

Service Code	HCPCS 82103
Hospital Charge Code	422821035
Hospital Revenue Code	301
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: MDX Hawaii PPO	$186.24

Alpha1-Antitrypsin DLS

Facility

$192.00

Service Code	HCPCS 82103
Hospital Charge Code	422821035
Hospital Revenue Code	301
Min. Negotiated Rate	$13.44
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$80.64
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$176.64
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.56
Rate for Payer: Hawaii Medical Service Association Commercial	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$80.64
Rate for Payer: Hawaii Western Management Group Commercial	$13.44
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$80.64
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$80.64
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$80.64
Rate for Payer: Ohana Health Plan Medicare	$80.64
Rate for Payer: UnitedHealthcare Medicaid	$18.56
Rate for Payer: UnitedHealthcare Medicare	$80.64
Rate for Payer: University Health Alliance Commercial	$34.72

ALPRAZolam 0.25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00228202710
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

ALPRAZolam 0.25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00228202710
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

ALPRAZolam 0.5 mg Tab [KMC]

Facility

$3.73

Service Code	NDC 00228202910
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.62
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Management Network Commercial	$3.17
Rate for Payer: Kaiser Permanente Commercial	$3.36
Rate for Payer: MDX Hawaii PPO	$3.62

ALPRAZolam 0.5 mg Tab [KMC]

Facility

$3.73

Service Code	NDC 00228202910
Hospital Revenue Code	250
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$3.62
Rate for Payer: AlohaCare Medicaid	$1.86
Rate for Payer: AlohaCare Medicare	$1.57
Rate for Payer: Cash Price	$2.42
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.43
Rate for Payer: Devoted Health Medicare	$1.57
Rate for Payer: Hawaii Medical Service Association Medicare	$1.57
Rate for Payer: Hawaii Western Management Group Commercial	$3.54
Rate for Payer: Health Management Network Commercial	$3.17
Rate for Payer: Humana Medicare	$1.57
Rate for Payer: Kaiser Permanente Commercial	$3.36
Rate for Payer: Kaiser Permanente Medicaid	$1.90
Rate for Payer: Kaiser Permanente Medicare	$1.57
Rate for Payer: MDX Hawaii PPO	$3.62
Rate for Payer: Ohana Health Plan Medicaid	$1.57
Rate for Payer: Ohana Health Plan Medicare	$1.57
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: UnitedHealthcare Medicare	$1.57
Rate for Payer: University Health Alliance Commercial	$2.72

ALPRAZolam 2 mg Tab [KMC]

Facility

$7.86

Service Code	NDC 00228203910
Hospital Revenue Code	250
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$7.62
Rate for Payer: AlohaCare Medicaid	$3.93
Rate for Payer: AlohaCare Medicare	$3.30
Rate for Payer: Cash Price	$5.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.23
Rate for Payer: Devoted Health Medicare	$3.30
Rate for Payer: Hawaii Medical Service Association Medicare	$3.30
Rate for Payer: Hawaii Western Management Group Commercial	$7.47
Rate for Payer: Health Management Network Commercial	$6.68
Rate for Payer: Humana Medicare	$3.30
Rate for Payer: Kaiser Permanente Commercial	$7.07
Rate for Payer: Kaiser Permanente Medicaid	$4.01
Rate for Payer: Kaiser Permanente Medicare	$3.30
Rate for Payer: MDX Hawaii PPO	$7.62
Rate for Payer: Ohana Health Plan Medicaid	$3.30
Rate for Payer: Ohana Health Plan Medicare	$3.30
Rate for Payer: UnitedHealthcare Medicaid	$4.72
Rate for Payer: UnitedHealthcare Medicare	$3.30
Rate for Payer: University Health Alliance Commercial	$5.73

ALPRAZolam 2 mg Tab [KMC]

Facility

$7.86

Service Code	NDC 00228203910
Hospital Revenue Code	250
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$7.62
Rate for Payer: Cash Price	$5.11
Rate for Payer: Health Management Network Commercial	$6.68
Rate for Payer: Kaiser Permanente Commercial	$7.07
Rate for Payer: MDX Hawaii PPO	$7.62

ALT

Facility

$72.00

Service Code	HCPCS 84460
Hospital Charge Code	422844600
Hospital Revenue Code	301
Min. Negotiated Rate	$5.30
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$30.24
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$66.24
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.32
Rate for Payer: Hawaii Medical Service Association Commercial	$6.62
Rate for Payer: Hawaii Medical Service Association Medicare	$30.24
Rate for Payer: Hawaii Western Management Group Commercial	$5.30
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$30.24
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$30.24
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$30.24
Rate for Payer: Ohana Health Plan Medicare	$30.24
Rate for Payer: UnitedHealthcare Medicaid	$7.32
Rate for Payer: UnitedHealthcare Medicare	$30.24
Rate for Payer: University Health Alliance Commercial	$13.69

ALT

Facility

$72.00

Service Code	HCPCS 84460
Hospital Charge Code	422844600
Hospital Revenue Code	301
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

alteplase 2 mg IV Inj [KMC]

Facility

$771.41

Service Code	HCPCS J2997
Hospital Revenue Code	636
Min. Negotiated Rate	$94.15
Max. Negotiated Rate	$748.27
Rate for Payer: AlohaCare Medicaid	$385.70
Rate for Payer: AlohaCare Medicare	$323.99
Rate for Payer: Cash Price	$501.42
Rate for Payer: Cash Price	$501.42
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$709.70
Rate for Payer: Devoted Health Medicare	$323.99
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$94.15
Rate for Payer: Hawaii Medical Service Association Commercial	$118.86
Rate for Payer: Hawaii Medical Service Association Medicare	$323.99
Rate for Payer: Hawaii Western Management Group Commercial	$732.84
Rate for Payer: Health Management Network Commercial	$655.70
Rate for Payer: Humana Medicare	$323.99
Rate for Payer: Kaiser Permanente Commercial	$694.27
Rate for Payer: Kaiser Permanente Medicaid	$393.42
Rate for Payer: Kaiser Permanente Medicare	$323.99
Rate for Payer: MDX Hawaii PPO	$748.27
Rate for Payer: Ohana Health Plan Medicaid	$323.99
Rate for Payer: Ohana Health Plan Medicare	$323.99
Rate for Payer: UnitedHealthcare Medicaid	$462.85
Rate for Payer: UnitedHealthcare Medicare	$323.99
Rate for Payer: University Health Alliance Commercial	$562.28

alteplase 2 mg IV Inj [KMC]

Facility

$771.41

Service Code	HCPCS J2997
Hospital Revenue Code	636
Min. Negotiated Rate	$655.70
Max. Negotiated Rate	$748.27
Rate for Payer: Cash Price	$501.42
Rate for Payer: Health Management Network Commercial	$655.70
Rate for Payer: Kaiser Permanente Commercial	$694.27
Rate for Payer: MDX Hawaii PPO	$748.27

aluminum chloride hexahydrate 20% topical Soln [KMC]

Facility

$1.00

Service Code	NDC 00096070737
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.65
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

aluminum chloride hexahydrate 20% topical Soln [KMC]

Facility

$1.00

Service Code	NDC 00096070737
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.42
Rate for Payer: Cash Price	$0.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.92
Rate for Payer: Devoted Health Medicare	$0.42
Rate for Payer: Hawaii Medical Service Association Medicare	$0.42
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.42
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.42
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.42
Rate for Payer: Ohana Health Plan Medicare	$0.42
Rate for Payer: UnitedHealthcare Medicaid	$0.60
Rate for Payer: UnitedHealthcare Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

aluminum sulfate-calcium acetate Top Pwdr [KMC]

Facility

$3.37

Service Code	NDC 16864024001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$3.27
Rate for Payer: Cash Price	$2.19
Rate for Payer: Health Management Network Commercial	$2.86
Rate for Payer: Kaiser Permanente Commercial	$3.03
Rate for Payer: MDX Hawaii PPO	$3.27

aluminum sulfate-calcium acetate Top Pwdr [KMC]

Facility

$3.37

Service Code	NDC 16864024001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$3.27
Rate for Payer: AlohaCare Medicaid	$1.69
Rate for Payer: AlohaCare Medicare	$1.42
Rate for Payer: Cash Price	$2.19
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.10
Rate for Payer: Devoted Health Medicare	$1.42
Rate for Payer: Hawaii Medical Service Association Medicare	$1.42
Rate for Payer: Hawaii Western Management Group Commercial	$3.20
Rate for Payer: Health Management Network Commercial	$2.86
Rate for Payer: Humana Medicare	$1.42
Rate for Payer: Kaiser Permanente Commercial	$3.03
Rate for Payer: Kaiser Permanente Medicaid	$1.72
Rate for Payer: Kaiser Permanente Medicare	$1.42
Rate for Payer: MDX Hawaii PPO	$3.27
Rate for Payer: Ohana Health Plan Medicaid	$1.42
Rate for Payer: Ohana Health Plan Medicare	$1.42
Rate for Payer: UnitedHealthcare Medicaid	$2.02
Rate for Payer: UnitedHealthcare Medicare	$1.42
Rate for Payer: University Health Alliance Commercial	$2.46

amantadine 100 mg Cap [KMC]

Facility

$7.75

Service Code	NDC 62332024631
Hospital Revenue Code	250
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$7.52
Rate for Payer: AlohaCare Medicaid	$3.88
Rate for Payer: AlohaCare Medicare	$3.25
Rate for Payer: Cash Price	$5.04
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.13
Rate for Payer: Devoted Health Medicare	$3.25
Rate for Payer: Hawaii Medical Service Association Medicare	$3.25
Rate for Payer: Hawaii Western Management Group Commercial	$7.36
Rate for Payer: Health Management Network Commercial	$6.59
Rate for Payer: Humana Medicare	$3.25
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: Kaiser Permanente Medicaid	$3.95
Rate for Payer: Kaiser Permanente Medicare	$3.25
Rate for Payer: MDX Hawaii PPO	$7.52
Rate for Payer: Ohana Health Plan Medicaid	$3.25
Rate for Payer: Ohana Health Plan Medicare	$3.25
Rate for Payer: UnitedHealthcare Medicaid	$4.65
Rate for Payer: UnitedHealthcare Medicare	$3.25
Rate for Payer: University Health Alliance Commercial	$5.65

amantadine 100 mg Cap [KMC]

Facility

$7.75

Service Code	NDC 62332024631
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$7.52
Rate for Payer: Cash Price	$5.04
Rate for Payer: Health Management Network Commercial	$6.59
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: MDX Hawaii PPO	$7.52

ambrisentan 10 mg Tab [KMC]

Facility

$1,331.18

Service Code	NDC 69097038702
Hospital Revenue Code	250
Min. Negotiated Rate	$1,131.50
Max. Negotiated Rate	$1,291.24
Rate for Payer: Cash Price	$865.27
Rate for Payer: Health Management Network Commercial	$1,131.50
Rate for Payer: Kaiser Permanente Commercial	$1,198.06
Rate for Payer: MDX Hawaii PPO	$1,291.24

ambrisentan 10 mg Tab [KMC]

Facility

$1,331.18

Service Code	NDC 69097038702
Hospital Revenue Code	250
Min. Negotiated Rate	$559.10
Max. Negotiated Rate	$1,291.24
Rate for Payer: AlohaCare Medicaid	$665.59
Rate for Payer: AlohaCare Medicare	$559.10
Rate for Payer: Cash Price	$865.27
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,224.69
Rate for Payer: Devoted Health Medicare	$559.10
Rate for Payer: Hawaii Medical Service Association Medicare	$559.10
Rate for Payer: Hawaii Western Management Group Commercial	$1,264.62
Rate for Payer: Health Management Network Commercial	$1,131.50
Rate for Payer: Humana Medicare	$559.10
Rate for Payer: Kaiser Permanente Commercial	$1,198.06
Rate for Payer: Kaiser Permanente Medicaid	$678.90
Rate for Payer: Kaiser Permanente Medicare	$559.10
Rate for Payer: MDX Hawaii PPO	$1,291.24
Rate for Payer: Ohana Health Plan Medicaid	$559.10
Rate for Payer: Ohana Health Plan Medicare	$559.10
Rate for Payer: UnitedHealthcare Medicaid	$798.71
Rate for Payer: UnitedHealthcare Medicare	$559.10
Rate for Payer: University Health Alliance Commercial	$970.30

Know your out-of-pocket cost for care.

All Charges