Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Microalbumin, 24 Hr Urine (w/ Creatinine) DLS

Facility

$134.00

Service Code	HCPCS 82043
Hospital Charge Code	422820435
Hospital Revenue Code	301
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

Microalbumin, 24 Hr Urine (w/ Creatinine) DLS

Facility

$134.00

Service Code	HCPCS 82043
Hospital Charge Code	422820435
Hospital Revenue Code	301
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$56.28
Rate for Payer: Cash Price	$87.10
Rate for Payer: Cash Price	$87.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$123.28
Rate for Payer: Devoted Health Medicare	$56.28
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$56.28
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$56.28
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$56.28
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$56.28
Rate for Payer: Ohana Health Plan Medicare	$56.28
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: UnitedHealthcare Medicare	$56.28
Rate for Payer: University Health Alliance Commercial	$14.97

MICROPORE TAPE 2"

Facility

$4.00

Hospital Charge Code	8179
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

MICROPORE TAPE 2"

Facility

$4.00

Hospital Charge Code	8179
Hospital Revenue Code	270
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

Microsporidia DLS

Facility

$402.00

Service Code	HCPCS 87207
Hospital Charge Code	422872075
Hospital Revenue Code	306
Min. Negotiated Rate	$5.99
Max. Negotiated Rate	$389.94
Rate for Payer: AlohaCare Medicaid	$201.00
Rate for Payer: AlohaCare Medicare	$168.84
Rate for Payer: Cash Price	$261.30
Rate for Payer: Cash Price	$261.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$369.84
Rate for Payer: Devoted Health Medicare	$168.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.37
Rate for Payer: Hawaii Medical Service Association Commercial	$7.49
Rate for Payer: Hawaii Medical Service Association Medicare	$168.84
Rate for Payer: Hawaii Western Management Group Commercial	$5.99
Rate for Payer: Health Management Network Commercial	$341.70
Rate for Payer: Humana Medicare	$168.84
Rate for Payer: Kaiser Permanente Commercial	$361.80
Rate for Payer: Kaiser Permanente Medicaid	$205.02
Rate for Payer: Kaiser Permanente Medicare	$168.84
Rate for Payer: MDX Hawaii PPO	$389.94
Rate for Payer: Ohana Health Plan Medicaid	$168.84
Rate for Payer: Ohana Health Plan Medicare	$168.84
Rate for Payer: UnitedHealthcare Medicaid	$8.37
Rate for Payer: UnitedHealthcare Medicare	$168.84
Rate for Payer: University Health Alliance Commercial	$15.48

Microsporidia DLS

Facility

$402.00

Service Code	HCPCS 87207
Hospital Charge Code	422872075
Hospital Revenue Code	306
Min. Negotiated Rate	$341.70
Max. Negotiated Rate	$389.94
Rate for Payer: Cash Price	$261.30
Rate for Payer: Health Management Network Commercial	$341.70
Rate for Payer: Kaiser Permanente Commercial	$361.80
Rate for Payer: MDX Hawaii PPO	$389.94

midazolam 2 mg/ 2 mL IM or IV Sol [KMC]

Facility

$1.56

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.51
Rate for Payer: Cash Price	$1.01
Rate for Payer: Health Management Network Commercial	$1.33
Rate for Payer: Kaiser Permanente Commercial	$1.40
Rate for Payer: MDX Hawaii PPO	$1.51

midazolam 2 mg/ 2 mL IM or IV Sol [KMC]

Facility

$1.56

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$1.51
Rate for Payer: AlohaCare Medicaid	$0.78
Rate for Payer: AlohaCare Medicare	$0.66
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cash Price	$1.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.44
Rate for Payer: Devoted Health Medicare	$0.66
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$0.66
Rate for Payer: Hawaii Western Management Group Commercial	$1.48
Rate for Payer: Health Management Network Commercial	$1.33
Rate for Payer: Humana Medicare	$0.66
Rate for Payer: Kaiser Permanente Commercial	$1.40
Rate for Payer: Kaiser Permanente Medicaid	$0.80
Rate for Payer: Kaiser Permanente Medicare	$0.66
Rate for Payer: MDX Hawaii PPO	$1.51
Rate for Payer: Ohana Health Plan Medicaid	$0.66
Rate for Payer: Ohana Health Plan Medicare	$0.66
Rate for Payer: UnitedHealthcare Medicaid	$0.94
Rate for Payer: UnitedHealthcare Medicare	$0.66
Rate for Payer: University Health Alliance Commercial	$1.14

midazolam 5 mg/mL inj (1 mL or 10 mL vials) [KMC]

Facility

$3.31

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$3.21
Rate for Payer: AlohaCare Medicaid	$1.66
Rate for Payer: AlohaCare Medicare	$1.39
Rate for Payer: Cash Price	$2.15
Rate for Payer: Cash Price	$2.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.05
Rate for Payer: Devoted Health Medicare	$1.39
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$1.39
Rate for Payer: Hawaii Western Management Group Commercial	$3.14
Rate for Payer: Health Management Network Commercial	$2.81
Rate for Payer: Humana Medicare	$1.39
Rate for Payer: Kaiser Permanente Commercial	$2.98
Rate for Payer: Kaiser Permanente Medicaid	$1.69
Rate for Payer: Kaiser Permanente Medicare	$1.39
Rate for Payer: MDX Hawaii PPO	$3.21
Rate for Payer: Ohana Health Plan Medicaid	$1.39
Rate for Payer: Ohana Health Plan Medicare	$1.39
Rate for Payer: UnitedHealthcare Medicaid	$1.99
Rate for Payer: UnitedHealthcare Medicare	$1.39
Rate for Payer: University Health Alliance Commercial	$2.41

midazolam 5 mg/mL inj (1 mL or 10 mL vials) [KMC]

Facility

$3.31

Service Code	HCPCS J2250
Hospital Revenue Code	636
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$3.21
Rate for Payer: Cash Price	$2.15
Rate for Payer: Health Management Network Commercial	$2.81
Rate for Payer: Kaiser Permanente Commercial	$2.98
Rate for Payer: MDX Hawaii PPO	$3.21

midodrine 10 mg Tab [KMC]

Facility

$35.81

Service Code	NDC 72603060701
Hospital Revenue Code	250
Min. Negotiated Rate	$30.44
Max. Negotiated Rate	$34.74
Rate for Payer: Cash Price	$23.28
Rate for Payer: Health Management Network Commercial	$30.44
Rate for Payer: Kaiser Permanente Commercial	$32.23
Rate for Payer: MDX Hawaii PPO	$34.74

midodrine 10 mg Tab [KMC]

Facility

$35.81

Service Code	NDC 72603060701
Hospital Revenue Code	250
Min. Negotiated Rate	$15.04
Max. Negotiated Rate	$34.74
Rate for Payer: AlohaCare Medicaid	$17.91
Rate for Payer: AlohaCare Medicare	$15.04
Rate for Payer: Cash Price	$23.28
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$32.95
Rate for Payer: Devoted Health Medicare	$15.04
Rate for Payer: Hawaii Medical Service Association Medicare	$15.04
Rate for Payer: Hawaii Western Management Group Commercial	$34.02
Rate for Payer: Health Management Network Commercial	$30.44
Rate for Payer: Humana Medicare	$15.04
Rate for Payer: Kaiser Permanente Commercial	$32.23
Rate for Payer: Kaiser Permanente Medicaid	$18.26
Rate for Payer: Kaiser Permanente Medicare	$15.04
Rate for Payer: MDX Hawaii PPO	$34.74
Rate for Payer: Ohana Health Plan Medicaid	$15.04
Rate for Payer: Ohana Health Plan Medicare	$15.04
Rate for Payer: UnitedHealthcare Medicaid	$21.49
Rate for Payer: UnitedHealthcare Medicare	$15.04
Rate for Payer: University Health Alliance Commercial	$26.10

midodrine 2.5 mg Tab [KMC]

Facility

$4.81

Service Code	NDC 00185004001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$4.67
Rate for Payer: AlohaCare Medicaid	$2.40
Rate for Payer: AlohaCare Medicare	$2.02
Rate for Payer: Cash Price	$3.13
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.43
Rate for Payer: Devoted Health Medicare	$2.02
Rate for Payer: Hawaii Medical Service Association Medicare	$2.02
Rate for Payer: Hawaii Western Management Group Commercial	$4.57
Rate for Payer: Health Management Network Commercial	$4.09
Rate for Payer: Humana Medicare	$2.02
Rate for Payer: Kaiser Permanente Commercial	$4.33
Rate for Payer: Kaiser Permanente Medicaid	$2.45
Rate for Payer: Kaiser Permanente Medicare	$2.02
Rate for Payer: MDX Hawaii PPO	$4.67
Rate for Payer: Ohana Health Plan Medicaid	$2.02
Rate for Payer: Ohana Health Plan Medicare	$2.02
Rate for Payer: UnitedHealthcare Medicaid	$2.89
Rate for Payer: UnitedHealthcare Medicare	$2.02
Rate for Payer: University Health Alliance Commercial	$3.51

midodrine 2.5 mg Tab [KMC]

Facility

$4.81

Service Code	NDC 00185004001
Hospital Revenue Code	250
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$4.67
Rate for Payer: Cash Price	$3.13
Rate for Payer: Health Management Network Commercial	$4.09
Rate for Payer: Kaiser Permanente Commercial	$4.33
Rate for Payer: MDX Hawaii PPO	$4.67

midodrine 5 mg Tab [KMC]

Facility

$15.33

Service Code	NDC 72603060601
Hospital Revenue Code	250
Min. Negotiated Rate	$13.03
Max. Negotiated Rate	$14.87
Rate for Payer: Cash Price	$9.96
Rate for Payer: Health Management Network Commercial	$13.03
Rate for Payer: Kaiser Permanente Commercial	$13.80
Rate for Payer: MDX Hawaii PPO	$14.87

midodrine 5 mg Tab [KMC]

Facility

$15.33

Service Code	NDC 72603060601
Hospital Revenue Code	250
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$14.87
Rate for Payer: AlohaCare Medicaid	$7.67
Rate for Payer: AlohaCare Medicare	$6.44
Rate for Payer: Cash Price	$9.96
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$14.10
Rate for Payer: Devoted Health Medicare	$6.44
Rate for Payer: Hawaii Medical Service Association Medicare	$6.44
Rate for Payer: Hawaii Western Management Group Commercial	$14.56
Rate for Payer: Health Management Network Commercial	$13.03
Rate for Payer: Humana Medicare	$6.44
Rate for Payer: Kaiser Permanente Commercial	$13.80
Rate for Payer: Kaiser Permanente Medicaid	$7.82
Rate for Payer: Kaiser Permanente Medicare	$6.44
Rate for Payer: MDX Hawaii PPO	$14.87
Rate for Payer: Ohana Health Plan Medicaid	$6.44
Rate for Payer: Ohana Health Plan Medicare	$6.44
Rate for Payer: UnitedHealthcare Medicaid	$9.20
Rate for Payer: UnitedHealthcare Medicare	$6.44
Rate for Payer: University Health Alliance Commercial	$11.17

MID STREAM KIT

Facility

$7.00

Hospital Charge Code	8180
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

MID STREAM KIT

Facility

$7.00

Hospital Charge Code	8180
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

MILD TO MOD DEP SYMP BY STAND DEP ASSESS TOOL

Professional

Both

$0.01

Service Code	HCPCS 3353F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

milnacipran 25 mg Tab [KMC]

Facility

$37.14

Service Code	NDC 00456152560
Hospital Revenue Code	250
Min. Negotiated Rate	$31.57
Max. Negotiated Rate	$36.03
Rate for Payer: Cash Price	$24.14
Rate for Payer: Health Management Network Commercial	$31.57
Rate for Payer: Kaiser Permanente Commercial	$33.43
Rate for Payer: MDX Hawaii PPO	$36.03

milnacipran 25 mg Tab [KMC]

Facility

$37.14

Service Code	NDC 00456152560
Hospital Revenue Code	250
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$36.03
Rate for Payer: AlohaCare Medicaid	$18.57
Rate for Payer: AlohaCare Medicare	$15.60
Rate for Payer: Cash Price	$24.14
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.17
Rate for Payer: Devoted Health Medicare	$15.60
Rate for Payer: Hawaii Medical Service Association Medicare	$15.60
Rate for Payer: Hawaii Western Management Group Commercial	$35.28
Rate for Payer: Health Management Network Commercial	$31.57
Rate for Payer: Humana Medicare	$15.60
Rate for Payer: Kaiser Permanente Commercial	$33.43
Rate for Payer: Kaiser Permanente Medicaid	$18.94
Rate for Payer: Kaiser Permanente Medicare	$15.60
Rate for Payer: MDX Hawaii PPO	$36.03
Rate for Payer: Ohana Health Plan Medicaid	$15.60
Rate for Payer: Ohana Health Plan Medicare	$15.60
Rate for Payer: UnitedHealthcare Medicaid	$22.28
Rate for Payer: UnitedHealthcare Medicare	$15.60
Rate for Payer: University Health Alliance Commercial	$27.07

Mineral Oil Enema Adult 133 mL [KMC]

Facility

$0.06

Service Code	NDC 00132030140
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Management Network Commercial	$0.05
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: MDX Hawaii PPO	$0.06

Mineral Oil Enema Adult 133 mL [KMC]

Facility

$0.06

Service Code	NDC 00132030140
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.06
Rate for Payer: AlohaCare Medicaid	$0.03
Rate for Payer: AlohaCare Medicare	$0.03
Rate for Payer: Cash Price	$0.04
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.06
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$0.06
Rate for Payer: Health Management Network Commercial	$0.05
Rate for Payer: Humana Medicare	$0.03
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: Kaiser Permanente Medicaid	$0.03
Rate for Payer: Kaiser Permanente Medicare	$0.03
Rate for Payer: MDX Hawaii PPO	$0.06
Rate for Payer: Ohana Health Plan Medicaid	$0.03
Rate for Payer: Ohana Health Plan Medicare	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.04
Rate for Payer: UnitedHealthcare Medicare	$0.03
Rate for Payer: University Health Alliance Commercial	$0.04

minocycline 100 mg Cap [KMC]

Facility

$13.59

Service Code	NDC 13668048450
Hospital Revenue Code	250
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$13.18
Rate for Payer: Cash Price	$8.83
Rate for Payer: Health Management Network Commercial	$11.55
Rate for Payer: Kaiser Permanente Commercial	$12.23
Rate for Payer: MDX Hawaii PPO	$13.18

minocycline 100 mg Cap [KMC]

Facility

$13.59

Service Code	NDC 13668048450
Hospital Revenue Code	250
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$13.18
Rate for Payer: AlohaCare Medicaid	$6.79
Rate for Payer: AlohaCare Medicare	$5.71
Rate for Payer: Cash Price	$8.83
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.50
Rate for Payer: Devoted Health Medicare	$5.71
Rate for Payer: Hawaii Medical Service Association Medicare	$5.71
Rate for Payer: Hawaii Western Management Group Commercial	$12.91
Rate for Payer: Health Management Network Commercial	$11.55
Rate for Payer: Humana Medicare	$5.71
Rate for Payer: Kaiser Permanente Commercial	$12.23
Rate for Payer: Kaiser Permanente Medicaid	$6.93
Rate for Payer: Kaiser Permanente Medicare	$5.71
Rate for Payer: MDX Hawaii PPO	$13.18
Rate for Payer: Ohana Health Plan Medicaid	$5.71
Rate for Payer: Ohana Health Plan Medicare	$5.71
Rate for Payer: UnitedHealthcare Medicaid	$8.15
Rate for Payer: UnitedHealthcare Medicare	$5.71
Rate for Payer: University Health Alliance Commercial	$9.91

Know your out-of-pocket cost for care.

All Charges