Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

mesalamine 400 mg DR Cap [KMC]

Facility

$16.76

Service Code	NDC 59762011701
Hospital Revenue Code	250
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$16.26
Rate for Payer: Cash Price	$10.89
Rate for Payer: Health Management Network Commercial	$14.25
Rate for Payer: Kaiser Permanente Commercial	$15.08
Rate for Payer: MDX Hawaii PPO	$16.26

mesalamine 400 mg DR Cap [KMC]

Facility

$16.76

Service Code	NDC 59762011701
Hospital Revenue Code	250
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$16.26
Rate for Payer: AlohaCare Medicaid	$8.38
Rate for Payer: AlohaCare Medicare	$7.04
Rate for Payer: Cash Price	$10.89
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.42
Rate for Payer: Devoted Health Medicare	$7.04
Rate for Payer: Hawaii Medical Service Association Medicare	$7.04
Rate for Payer: Hawaii Western Management Group Commercial	$15.92
Rate for Payer: Health Management Network Commercial	$14.25
Rate for Payer: Humana Medicare	$7.04
Rate for Payer: Kaiser Permanente Commercial	$15.08
Rate for Payer: Kaiser Permanente Medicaid	$8.55
Rate for Payer: Kaiser Permanente Medicare	$7.04
Rate for Payer: MDX Hawaii PPO	$16.26
Rate for Payer: Ohana Health Plan Medicaid	$7.04
Rate for Payer: Ohana Health Plan Medicare	$7.04
Rate for Payer: UnitedHealthcare Medicaid	$10.06
Rate for Payer: UnitedHealthcare Medicare	$7.04
Rate for Payer: University Health Alliance Commercial	$12.22

mesalamine 800 mg DR Tab [KMC]

Facility

$37.10

Service Code	NDC 68382043528
Hospital Revenue Code	250
Min. Negotiated Rate	$31.54
Max. Negotiated Rate	$35.99
Rate for Payer: Cash Price	$24.12
Rate for Payer: Health Management Network Commercial	$31.54
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: MDX Hawaii PPO	$35.99

mesalamine 800 mg DR Tab [KMC]

Facility

$37.10

Service Code	NDC 68382043528
Hospital Revenue Code	250
Min. Negotiated Rate	$15.58
Max. Negotiated Rate	$35.99
Rate for Payer: AlohaCare Medicaid	$18.55
Rate for Payer: AlohaCare Medicare	$15.58
Rate for Payer: Cash Price	$24.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.13
Rate for Payer: Devoted Health Medicare	$15.58
Rate for Payer: Hawaii Medical Service Association Medicare	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$35.24
Rate for Payer: Health Management Network Commercial	$31.54
Rate for Payer: Humana Medicare	$15.58
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: Kaiser Permanente Medicaid	$18.92
Rate for Payer: Kaiser Permanente Medicare	$15.58
Rate for Payer: MDX Hawaii PPO	$35.99
Rate for Payer: Ohana Health Plan Medicaid	$15.58
Rate for Payer: Ohana Health Plan Medicare	$15.58
Rate for Payer: UnitedHealthcare Medicaid	$22.26
Rate for Payer: UnitedHealthcare Medicare	$15.58
Rate for Payer: University Health Alliance Commercial	$27.04

Metanephrines, Fractionated, Free DLS

Facility

$257.00

Service Code	HCPCS 83835
Hospital Charge Code	422838355
Hospital Revenue Code	301
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$167.05
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: MDX Hawaii PPO	$249.29

Metanephrines, Fractionated, Free DLS

Facility

$257.00

Service Code	HCPCS 83835
Hospital Charge Code	422838355
Hospital Revenue Code	301
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$249.29
Rate for Payer: AlohaCare Medicaid	$128.50
Rate for Payer: AlohaCare Medicare	$107.94
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$236.44
Rate for Payer: Devoted Health Medicare	$107.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$23.41
Rate for Payer: Hawaii Medical Service Association Commercial	$21.18
Rate for Payer: Hawaii Medical Service Association Medicare	$107.94
Rate for Payer: Hawaii Western Management Group Commercial	$16.94
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Humana Medicare	$107.94
Rate for Payer: Kaiser Permanente Commercial	$231.30
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: Kaiser Permanente Medicare	$107.94
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: Ohana Health Plan Medicaid	$107.94
Rate for Payer: Ohana Health Plan Medicare	$107.94
Rate for Payer: UnitedHealthcare Medicaid	$23.41
Rate for Payer: UnitedHealthcare Medicare	$107.94
Rate for Payer: University Health Alliance Commercial	$43.79

metFORMIN 1000 mg Tab [KMC]

Facility

$5.76

Service Code	NDC 42385094901
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$5.59
Rate for Payer: Cash Price	$3.74
Rate for Payer: Health Management Network Commercial	$4.90
Rate for Payer: Kaiser Permanente Commercial	$5.18
Rate for Payer: MDX Hawaii PPO	$5.59

metFORMIN 1000 mg Tab [KMC]

Facility

$5.76

Service Code	NDC 42385094901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$5.59
Rate for Payer: AlohaCare Medicaid	$2.88
Rate for Payer: AlohaCare Medicare	$2.42
Rate for Payer: Cash Price	$3.74
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.30
Rate for Payer: Devoted Health Medicare	$2.42
Rate for Payer: Hawaii Medical Service Association Medicare	$2.42
Rate for Payer: Hawaii Western Management Group Commercial	$5.47
Rate for Payer: Health Management Network Commercial	$4.90
Rate for Payer: Humana Medicare	$2.42
Rate for Payer: Kaiser Permanente Commercial	$5.18
Rate for Payer: Kaiser Permanente Medicaid	$2.94
Rate for Payer: Kaiser Permanente Medicare	$2.42
Rate for Payer: MDX Hawaii PPO	$5.59
Rate for Payer: Ohana Health Plan Medicaid	$2.42
Rate for Payer: Ohana Health Plan Medicare	$2.42
Rate for Payer: UnitedHealthcare Medicaid	$3.46
Rate for Payer: UnitedHealthcare Medicare	$2.42
Rate for Payer: University Health Alliance Commercial	$4.20

metFORMIN 500 mg ER Tab [KMC]

Facility

$3.00

Service Code	NDC 42291049790
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

metFORMIN 500 mg ER Tab [KMC]

Facility

$3.00

Service Code	NDC 42291049790
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

metFORMIN 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 70010006301
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

metFORMIN 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 70010006301
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

metFORMIN 750 mg ER Tab [KMC]

Facility

$4.78

Service Code	NDC 67877041401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.06
Max. Negotiated Rate	$4.64
Rate for Payer: Cash Price	$3.11
Rate for Payer: Health Management Network Commercial	$4.06
Rate for Payer: Kaiser Permanente Commercial	$4.30
Rate for Payer: MDX Hawaii PPO	$4.64

metFORMIN 750 mg ER Tab [KMC]

Facility

$4.78

Service Code	NDC 67877041401
Hospital Revenue Code	250
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$4.64
Rate for Payer: AlohaCare Medicaid	$2.39
Rate for Payer: AlohaCare Medicare	$2.01
Rate for Payer: Cash Price	$3.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.40
Rate for Payer: Devoted Health Medicare	$2.01
Rate for Payer: Hawaii Medical Service Association Medicare	$2.01
Rate for Payer: Hawaii Western Management Group Commercial	$4.54
Rate for Payer: Health Management Network Commercial	$4.06
Rate for Payer: Humana Medicare	$2.01
Rate for Payer: Kaiser Permanente Commercial	$4.30
Rate for Payer: Kaiser Permanente Medicaid	$2.44
Rate for Payer: Kaiser Permanente Medicare	$2.01
Rate for Payer: MDX Hawaii PPO	$4.64
Rate for Payer: Ohana Health Plan Medicaid	$2.01
Rate for Payer: Ohana Health Plan Medicare	$2.01
Rate for Payer: UnitedHealthcare Medicaid	$2.87
Rate for Payer: UnitedHealthcare Medicare	$2.01
Rate for Payer: University Health Alliance Commercial	$3.48

metFORMIN 850 mg Tab [KMC]

Facility

$4.79

Service Code	NDC 42385094801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$4.65
Rate for Payer: AlohaCare Medicaid	$2.40
Rate for Payer: AlohaCare Medicare	$2.01
Rate for Payer: Cash Price	$3.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.41
Rate for Payer: Devoted Health Medicare	$2.01
Rate for Payer: Hawaii Medical Service Association Medicare	$2.01
Rate for Payer: Hawaii Western Management Group Commercial	$4.55
Rate for Payer: Health Management Network Commercial	$4.07
Rate for Payer: Humana Medicare	$2.01
Rate for Payer: Kaiser Permanente Commercial	$4.31
Rate for Payer: Kaiser Permanente Medicaid	$2.44
Rate for Payer: Kaiser Permanente Medicare	$2.01
Rate for Payer: MDX Hawaii PPO	$4.65
Rate for Payer: Ohana Health Plan Medicaid	$2.01
Rate for Payer: Ohana Health Plan Medicare	$2.01
Rate for Payer: UnitedHealthcare Medicaid	$2.87
Rate for Payer: UnitedHealthcare Medicare	$2.01
Rate for Payer: University Health Alliance Commercial	$3.49

metFORMIN 850 mg Tab [KMC]

Facility

$4.79

Service Code	NDC 42385094801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.07
Max. Negotiated Rate	$4.65
Rate for Payer: Cash Price	$3.11
Rate for Payer: Health Management Network Commercial	$4.07
Rate for Payer: Kaiser Permanente Commercial	$4.31
Rate for Payer: MDX Hawaii PPO	$4.65

methacholine varying strength Soln [KMC]

Facility

$36.00

Service Code	HCPCS J7674
Hospital Revenue Code	636
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

methacholine varying strength Soln [KMC]

Facility

$36.00

Service Code	HCPCS J7674
Hospital Revenue Code	636
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$15.12
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.12
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.73
Rate for Payer: Hawaii Medical Service Association Medicare	$15.12
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$15.12
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$15.12
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$15.12
Rate for Payer: Ohana Health Plan Medicare	$15.12
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: UnitedHealthcare Medicare	$15.12
Rate for Payer: University Health Alliance Commercial	$26.24

methadone 10 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS S0109
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

methadone 10 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS S0109
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

methadone 5 mg/5 mL Sol [KMC]

Facility

$0.37

Service Code	HCPCS S0109
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.24
Rate for Payer: Health Management Network Commercial	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.33
Rate for Payer: MDX Hawaii PPO	$0.36

methadone 5 mg/5 mL Sol [KMC]

Facility

$0.37

Service Code	HCPCS S0109
Hospital Revenue Code	637
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.36
Rate for Payer: AlohaCare Medicaid	$0.19
Rate for Payer: AlohaCare Medicare	$0.16
Rate for Payer: Cash Price	$0.24
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.34
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$0.35
Rate for Payer: Health Management Network Commercial	$0.31
Rate for Payer: Humana Medicare	$0.16
Rate for Payer: Kaiser Permanente Commercial	$0.33
Rate for Payer: Kaiser Permanente Medicaid	$0.19
Rate for Payer: Kaiser Permanente Medicare	$0.16
Rate for Payer: MDX Hawaii PPO	$0.36
Rate for Payer: Ohana Health Plan Medicaid	$0.16
Rate for Payer: Ohana Health Plan Medicare	$0.16
Rate for Payer: UnitedHealthcare Medicare	$0.16
Rate for Payer: University Health Alliance Commercial	$0.27

methadone 5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS S0109
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

methadone 5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS S0109
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

methenamine hippurate 1 gm Tab [KMC]

Facility

$8.37

Service Code	NDC 65862078201
Hospital Revenue Code	250
Min. Negotiated Rate	$7.11
Max. Negotiated Rate	$8.12
Rate for Payer: Cash Price	$5.44
Rate for Payer: Health Management Network Commercial	$7.11
Rate for Payer: Kaiser Permanente Commercial	$7.53
Rate for Payer: MDX Hawaii PPO	$8.12

Know your out-of-pocket cost for care.

All Charges