Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

melatonin 3 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 50268052415
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

melatonin 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 20555003901
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

melatonin 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 20555003901
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

meloxicam 15 mg Tab [KMC]

Facility

$19.38

Service Code	NDC 68382005105
Hospital Revenue Code	250
Min. Negotiated Rate	$8.14
Max. Negotiated Rate	$18.80
Rate for Payer: AlohaCare Medicaid	$9.69
Rate for Payer: AlohaCare Medicare	$8.14
Rate for Payer: Cash Price	$12.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$17.83
Rate for Payer: Devoted Health Medicare	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$8.14
Rate for Payer: Hawaii Western Management Group Commercial	$18.41
Rate for Payer: Health Management Network Commercial	$16.47
Rate for Payer: Humana Medicare	$8.14
Rate for Payer: Kaiser Permanente Commercial	$17.44
Rate for Payer: Kaiser Permanente Medicaid	$9.88
Rate for Payer: Kaiser Permanente Medicare	$8.14
Rate for Payer: MDX Hawaii PPO	$18.80
Rate for Payer: Ohana Health Plan Medicaid	$8.14
Rate for Payer: Ohana Health Plan Medicare	$8.14
Rate for Payer: UnitedHealthcare Medicaid	$11.63
Rate for Payer: UnitedHealthcare Medicare	$8.14
Rate for Payer: University Health Alliance Commercial	$14.13

meloxicam 15 mg Tab [KMC]

Facility

$19.38

Service Code	NDC 68382005105
Hospital Revenue Code	250
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$18.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$16.47
Rate for Payer: Kaiser Permanente Commercial	$17.44
Rate for Payer: MDX Hawaii PPO	$18.80

meloxicam 7.5 mg Tab [KMC]

Facility

$12.67

Service Code	NDC 68382005001
Hospital Revenue Code	250
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$12.29
Rate for Payer: AlohaCare Medicaid	$6.33
Rate for Payer: AlohaCare Medicare	$5.32
Rate for Payer: Cash Price	$8.24
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.66
Rate for Payer: Devoted Health Medicare	$5.32
Rate for Payer: Hawaii Medical Service Association Medicare	$5.32
Rate for Payer: Hawaii Western Management Group Commercial	$12.04
Rate for Payer: Health Management Network Commercial	$10.77
Rate for Payer: Humana Medicare	$5.32
Rate for Payer: Kaiser Permanente Commercial	$11.40
Rate for Payer: Kaiser Permanente Medicaid	$6.46
Rate for Payer: Kaiser Permanente Medicare	$5.32
Rate for Payer: MDX Hawaii PPO	$12.29
Rate for Payer: Ohana Health Plan Medicaid	$5.32
Rate for Payer: Ohana Health Plan Medicare	$5.32
Rate for Payer: UnitedHealthcare Medicaid	$7.60
Rate for Payer: UnitedHealthcare Medicare	$5.32
Rate for Payer: University Health Alliance Commercial	$9.24

meloxicam 7.5 mg Tab [KMC]

Facility

$12.67

Service Code	NDC 68382005001
Hospital Revenue Code	250
Min. Negotiated Rate	$10.77
Max. Negotiated Rate	$12.29
Rate for Payer: Cash Price	$8.24
Rate for Payer: Health Management Network Commercial	$10.77
Rate for Payer: Kaiser Permanente Commercial	$11.40
Rate for Payer: MDX Hawaii PPO	$12.29

memantine 14 mg ER cap [KMC]

Facility

$61.12

Service Code	NDC 60505620903
Hospital Revenue Code	250
Min. Negotiated Rate	$51.95
Max. Negotiated Rate	$59.29
Rate for Payer: Cash Price	$39.73
Rate for Payer: Health Management Network Commercial	$51.95
Rate for Payer: Kaiser Permanente Commercial	$55.01
Rate for Payer: MDX Hawaii PPO	$59.29

memantine 14 mg ER cap [KMC]

Facility

$61.12

Service Code	NDC 60505620903
Hospital Revenue Code	250
Min. Negotiated Rate	$25.67
Max. Negotiated Rate	$59.29
Rate for Payer: AlohaCare Medicaid	$30.56
Rate for Payer: AlohaCare Medicare	$25.67
Rate for Payer: Cash Price	$39.73
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$56.23
Rate for Payer: Devoted Health Medicare	$25.67
Rate for Payer: Hawaii Medical Service Association Medicare	$25.67
Rate for Payer: Hawaii Western Management Group Commercial	$58.06
Rate for Payer: Health Management Network Commercial	$51.95
Rate for Payer: Humana Medicare	$25.67
Rate for Payer: Kaiser Permanente Commercial	$55.01
Rate for Payer: Kaiser Permanente Medicaid	$31.17
Rate for Payer: Kaiser Permanente Medicare	$25.67
Rate for Payer: MDX Hawaii PPO	$59.29
Rate for Payer: Ohana Health Plan Medicaid	$25.67
Rate for Payer: Ohana Health Plan Medicare	$25.67
Rate for Payer: UnitedHealthcare Medicaid	$36.67
Rate for Payer: UnitedHealthcare Medicare	$25.67
Rate for Payer: University Health Alliance Commercial	$44.55

memantine 28 mg ER capsule [KMC]

Facility

$47.50

Service Code	NDC 00456342833
Hospital Revenue Code	250
Min. Negotiated Rate	$40.38
Max. Negotiated Rate	$46.08
Rate for Payer: Cash Price	$30.88
Rate for Payer: Health Management Network Commercial	$40.38
Rate for Payer: Kaiser Permanente Commercial	$42.75
Rate for Payer: MDX Hawaii PPO	$46.08

memantine 28 mg ER capsule [KMC]

Facility

$47.50

Service Code	NDC 00456342833
Hospital Revenue Code	250
Min. Negotiated Rate	$19.95
Max. Negotiated Rate	$46.08
Rate for Payer: AlohaCare Medicaid	$23.75
Rate for Payer: AlohaCare Medicare	$19.95
Rate for Payer: Cash Price	$30.88
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$43.70
Rate for Payer: Devoted Health Medicare	$19.95
Rate for Payer: Hawaii Medical Service Association Medicare	$19.95
Rate for Payer: Hawaii Western Management Group Commercial	$45.12
Rate for Payer: Health Management Network Commercial	$40.38
Rate for Payer: Humana Medicare	$19.95
Rate for Payer: Kaiser Permanente Commercial	$42.75
Rate for Payer: Kaiser Permanente Medicaid	$24.23
Rate for Payer: Kaiser Permanente Medicare	$19.95
Rate for Payer: MDX Hawaii PPO	$46.08
Rate for Payer: Ohana Health Plan Medicaid	$19.95
Rate for Payer: Ohana Health Plan Medicare	$19.95
Rate for Payer: UnitedHealthcare Medicaid	$28.50
Rate for Payer: UnitedHealthcare Medicare	$19.95
Rate for Payer: University Health Alliance Commercial	$34.62

memantine 5 mg Tab [KMC]

Facility

$21.24

Service Code	NDC 00456320560
Hospital Revenue Code	250
Min. Negotiated Rate	$8.92
Max. Negotiated Rate	$20.60
Rate for Payer: AlohaCare Medicaid	$10.62
Rate for Payer: AlohaCare Medicare	$8.92
Rate for Payer: Cash Price	$13.81
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$19.54
Rate for Payer: Devoted Health Medicare	$8.92
Rate for Payer: Hawaii Medical Service Association Medicare	$8.92
Rate for Payer: Hawaii Western Management Group Commercial	$20.18
Rate for Payer: Health Management Network Commercial	$18.05
Rate for Payer: Humana Medicare	$8.92
Rate for Payer: Kaiser Permanente Commercial	$19.12
Rate for Payer: Kaiser Permanente Medicaid	$10.83
Rate for Payer: Kaiser Permanente Medicare	$8.92
Rate for Payer: MDX Hawaii PPO	$20.60
Rate for Payer: Ohana Health Plan Medicaid	$8.92
Rate for Payer: Ohana Health Plan Medicare	$8.92
Rate for Payer: UnitedHealthcare Medicaid	$12.74
Rate for Payer: UnitedHealthcare Medicare	$8.92
Rate for Payer: University Health Alliance Commercial	$15.48

memantine 5 mg Tab [KMC]

Facility

$21.24

Service Code	NDC 00456320560
Hospital Revenue Code	250
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$20.60
Rate for Payer: Cash Price	$13.81
Rate for Payer: Health Management Network Commercial	$18.05
Rate for Payer: Kaiser Permanente Commercial	$19.12
Rate for Payer: MDX Hawaii PPO	$20.60

MEMORY CURRENT STATUS

Professional

Both

$0.01

Service Code	HCPCS G9168
Hospital Revenue Code	440
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

MEMORY CURRENT STATUS Speech

Facility

$1.00

Service Code	HCPCS G9168 GN
Hospital Charge Code	432G91680
Hospital Revenue Code	440
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

MEMORY CURRENT STATUS Speech

Facility

$1.00

Service Code	HCPCS G9168 GN
Hospital Charge Code	432G91680
Hospital Revenue Code	440
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 Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

MEMORY D/C STATUS

Professional

Both

$0.01

Service Code	HCPCS G9170
Hospital Revenue Code	440
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

MEMORY D/C STATUS Speech

Facility

$1.00

Service Code	HCPCS G9170 GN
Hospital Charge Code	432G91700
Hospital Revenue Code	440
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 Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

MEMORY D/C STATUS Speech

Facility

$1.00

Service Code	HCPCS G9170 GN
Hospital Charge Code	432G91700
Hospital Revenue Code	440
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

MEMORY GOAL STATUS

Professional

Both

$0.01

Service Code	HCPCS G9169
Hospital Revenue Code	440
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

MEMORY GOAL STATUS Speech

Facility

$1.00

Service Code	HCPCS G9169 GN
Hospital Charge Code	432G91690
Hospital Revenue Code	440
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

MEMORY GOAL STATUS Speech

Facility

$1.00

Service Code	HCPCS G9169 GN
Hospital Charge Code	432G91690
Hospital Revenue Code	440
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 Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE

Professional

Both

$454.00

Service Code	HCPCS 90734
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$385.90
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$295.10
Rate for Payer: Cash Price	$295.10
Rate for Payer: Hawaii Western Management Group Commercial	$125.47
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE

Professional

Both

$0.01

Service Code	HCPCS 90734 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$125.47
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$125.47
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

MENB-4C RECOMBNT PROT & OUTER MEMB VESIC VACC IM

Professional

Both

$263.00

Service Code	HCPCS 90620
Hospital Revenue Code	636
Min. Negotiated Rate	$193.50
Max. Negotiated Rate	$223.55
Rate for Payer: Cash Price	$170.95
Rate for Payer: Cash Price	$170.95
Rate for Payer: Hawaii Western Management Group Commercial	$193.50
Rate for Payer: Health Management Network Commercial	$223.55

Know your out-of-pocket cost for care.

All Charges