Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

minocycline 50 mg Cap [KMC]

Facility

$6.79

Service Code	NDC 65862020901
Hospital Revenue Code	250
Min. Negotiated Rate	$5.77
Max. Negotiated Rate	$6.59
Rate for Payer: Cash Price	$4.41
Rate for Payer: Health Management Network Commercial	$5.77
Rate for Payer: Kaiser Permanente Commercial	$6.11
Rate for Payer: MDX Hawaii PPO	$6.59

minocycline 50 mg Cap [KMC]

Facility

$6.79

Service Code	NDC 65862020901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$6.59
Rate for Payer: AlohaCare Medicaid	$3.40
Rate for Payer: AlohaCare Medicare	$2.85
Rate for Payer: Cash Price	$4.41
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.25
Rate for Payer: Devoted Health Medicare	$2.85
Rate for Payer: Hawaii Medical Service Association Medicare	$2.85
Rate for Payer: Hawaii Western Management Group Commercial	$6.45
Rate for Payer: Health Management Network Commercial	$5.77
Rate for Payer: Humana Medicare	$2.85
Rate for Payer: Kaiser Permanente Commercial	$6.11
Rate for Payer: Kaiser Permanente Medicaid	$3.46
Rate for Payer: Kaiser Permanente Medicare	$2.85
Rate for Payer: MDX Hawaii PPO	$6.59
Rate for Payer: Ohana Health Plan Medicaid	$2.85
Rate for Payer: Ohana Health Plan Medicare	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$4.07
Rate for Payer: UnitedHealthcare Medicare	$2.85
Rate for Payer: University Health Alliance Commercial	$4.95

MINOR BLADDER PROCEDURES WITH CC

Facility

$24,365.66

Service Code	MSDRG 663
Min. Negotiated Rate	$24,365.66
Max. Negotiated Rate	$24,365.66
Rate for Payer: Hawaii Medical Service Association Commercial	$24,365.66

MINOR BLADDER PROCEDURES WITH MCC

Facility

$32,827.27

Service Code	MSDRG 662
Min. Negotiated Rate	$32,827.27
Max. Negotiated Rate	$32,827.27
Rate for Payer: Hawaii Medical Service Association Commercial	$32,827.27

MINOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$19,151.22

Service Code	MSDRG 664
Min. Negotiated Rate	$19,151.22
Max. Negotiated Rate	$19,151.22
Rate for Payer: Hawaii Medical Service Association Commercial	$19,151.22

MINOR SKIN DISORDERS WITH MCC

Facility

$13,913.07

Service Code	MSDRG 606
Min. Negotiated Rate	$13,913.07
Max. Negotiated Rate	$13,913.07
Rate for Payer: Hawaii Medical Service Association Commercial	$13,913.07

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$12,538.36

Service Code	MSDRG 607
Min. Negotiated Rate	$12,538.36
Max. Negotiated Rate	$12,538.36
Rate for Payer: Hawaii Medical Service Association Commercial	$12,538.36

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$32,448.04

Service Code	MSDRG 345
Min. Negotiated Rate	$32,448.04
Max. Negotiated Rate	$32,448.04
Rate for Payer: Hawaii Medical Service Association Commercial	$32,448.04

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$36,287.76

Service Code	MSDRG 344
Min. Negotiated Rate	$36,287.76
Max. Negotiated Rate	$36,287.76
Rate for Payer: Hawaii Medical Service Association Commercial	$36,287.76

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$26,688.45

Service Code	MSDRG 346
Min. Negotiated Rate	$26,688.45
Max. Negotiated Rate	$26,688.45
Rate for Payer: Hawaii Medical Service Association Commercial	$26,688.45

minoxidil 2.5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00591564201
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

minoxidil 2.5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00591564201
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

mirabegron 25 mg ER tab [KMC]

Facility

$66.28

Service Code	NDC 68180015106
Hospital Revenue Code	250
Min. Negotiated Rate	$27.84
Max. Negotiated Rate	$64.29
Rate for Payer: AlohaCare Medicaid	$33.14
Rate for Payer: AlohaCare Medicare	$27.84
Rate for Payer: Cash Price	$43.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$60.98
Rate for Payer: Devoted Health Medicare	$27.84
Rate for Payer: Hawaii Medical Service Association Medicare	$27.84
Rate for Payer: Hawaii Western Management Group Commercial	$62.97
Rate for Payer: Health Management Network Commercial	$56.34
Rate for Payer: Humana Medicare	$27.84
Rate for Payer: Kaiser Permanente Commercial	$59.65
Rate for Payer: Kaiser Permanente Medicaid	$33.80
Rate for Payer: Kaiser Permanente Medicare	$27.84
Rate for Payer: MDX Hawaii PPO	$64.29
Rate for Payer: Ohana Health Plan Medicaid	$27.84
Rate for Payer: Ohana Health Plan Medicare	$27.84
Rate for Payer: UnitedHealthcare Medicaid	$39.77
Rate for Payer: UnitedHealthcare Medicare	$27.84
Rate for Payer: University Health Alliance Commercial	$48.31

mirabegron 25 mg ER tab [KMC]

Facility

$66.28

Service Code	NDC 68180015106
Hospital Revenue Code	250
Min. Negotiated Rate	$56.34
Max. Negotiated Rate	$64.29
Rate for Payer: Cash Price	$43.08
Rate for Payer: Health Management Network Commercial	$56.34
Rate for Payer: Kaiser Permanente Commercial	$59.65
Rate for Payer: MDX Hawaii PPO	$64.29

mirabegron 50 mg ER Tab

Facility

$33.36

Service Code	NDC 00469260230
Hospital Revenue Code	250
Min. Negotiated Rate	$14.01
Max. Negotiated Rate	$32.36
Rate for Payer: AlohaCare Medicaid	$16.68
Rate for Payer: AlohaCare Medicare	$14.01
Rate for Payer: Cash Price	$21.68
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$30.69
Rate for Payer: Devoted Health Medicare	$14.01
Rate for Payer: Hawaii Medical Service Association Medicare	$14.01
Rate for Payer: Hawaii Western Management Group Commercial	$31.69
Rate for Payer: Health Management Network Commercial	$28.36
Rate for Payer: Humana Medicare	$14.01
Rate for Payer: Kaiser Permanente Commercial	$30.02
Rate for Payer: Kaiser Permanente Medicaid	$17.01
Rate for Payer: Kaiser Permanente Medicare	$14.01
Rate for Payer: MDX Hawaii PPO	$32.36
Rate for Payer: Ohana Health Plan Medicaid	$14.01
Rate for Payer: Ohana Health Plan Medicare	$14.01
Rate for Payer: UnitedHealthcare Medicaid	$20.02
Rate for Payer: UnitedHealthcare Medicare	$14.01
Rate for Payer: University Health Alliance Commercial	$24.32

mirabegron 50 mg ER Tab

Facility

$33.36

Service Code	NDC 00469260230
Hospital Revenue Code	250
Min. Negotiated Rate	$28.36
Max. Negotiated Rate	$32.36
Rate for Payer: Cash Price	$21.68
Rate for Payer: Health Management Network Commercial	$28.36
Rate for Payer: Kaiser Permanente Commercial	$30.02
Rate for Payer: MDX Hawaii PPO	$32.36

mirtazapine 15 mg Tab [KMC]

Facility

$10.86

Service Code	NDC 51079008620
Hospital Revenue Code	250
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$10.53
Rate for Payer: AlohaCare Medicaid	$5.43
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$7.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.99
Rate for Payer: Devoted Health Medicare	$4.56
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$10.32
Rate for Payer: Health Management Network Commercial	$9.23
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$9.77
Rate for Payer: Kaiser Permanente Medicaid	$5.54
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$10.53
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicaid	$6.52
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$7.92

mirtazapine 15 mg Tab [KMC]

Facility

$10.86

Service Code	NDC 51079008620
Hospital Revenue Code	250
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$10.53
Rate for Payer: Cash Price	$7.06
Rate for Payer: Health Management Network Commercial	$9.23
Rate for Payer: Kaiser Permanente Commercial	$9.77
Rate for Payer: MDX Hawaii PPO	$10.53

mirtazapine 7.5 mg Tab [KMC]

Facility

$10.53

Service Code	NDC 72603055801
Hospital Revenue Code	250
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$10.21
Rate for Payer: Cash Price	$6.84
Rate for Payer: Health Management Network Commercial	$8.95
Rate for Payer: Kaiser Permanente Commercial	$9.48
Rate for Payer: MDX Hawaii PPO	$10.21

mirtazapine 7.5 mg Tab [KMC]

Facility

$10.53

Service Code	NDC 72603055801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$10.21
Rate for Payer: AlohaCare Medicaid	$5.26
Rate for Payer: AlohaCare Medicare	$4.42
Rate for Payer: Cash Price	$6.84
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.69
Rate for Payer: Devoted Health Medicare	$4.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.42
Rate for Payer: Hawaii Western Management Group Commercial	$10.00
Rate for Payer: Health Management Network Commercial	$8.95
Rate for Payer: Humana Medicare	$4.42
Rate for Payer: Kaiser Permanente Commercial	$9.48
Rate for Payer: Kaiser Permanente Medicaid	$5.37
Rate for Payer: Kaiser Permanente Medicare	$4.42
Rate for Payer: MDX Hawaii PPO	$10.21
Rate for Payer: Ohana Health Plan Medicaid	$4.42
Rate for Payer: Ohana Health Plan Medicare	$4.42
Rate for Payer: UnitedHealthcare Medicaid	$6.32
Rate for Payer: UnitedHealthcare Medicare	$4.42
Rate for Payer: University Health Alliance Commercial	$7.68

Miscellaneous Culture DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

Miscellaneous Culture DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$54.18
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.68
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$54.18
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$54.18
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$54.18
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$54.18
Rate for Payer: Ohana Health Plan Medicare	$54.18
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$54.18
Rate for Payer: University Health Alliance Commercial	$22.26

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$20,217.81

Service Code	MSDRG 640
Min. Negotiated Rate	$20,217.81
Max. Negotiated Rate	$20,217.81
Rate for Payer: Hawaii Medical Service Association Commercial	$20,217.81

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$15,738.13

Service Code	MSDRG 641
Min. Negotiated Rate	$15,738.13
Max. Negotiated Rate	$15,738.13
Rate for Payer: Hawaii Medical Service Association Commercial	$15,738.13

Misc Sensitivites. By E-test DLS

Facility

$52.00

Service Code	HCPCS 87181
Hospital Charge Code	422871815
Hospital Revenue Code	306
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$50.44
Rate for Payer: AlohaCare Medicaid	$26.00
Rate for Payer: AlohaCare Medicare	$21.84
Rate for Payer: Cash Price	$33.80
Rate for Payer: Cash Price	$33.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$47.84
Rate for Payer: Devoted Health Medicare	$21.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.57
Rate for Payer: Hawaii Medical Service Association Commercial	$5.94
Rate for Payer: Hawaii Medical Service Association Medicare	$21.84
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Humana Medicare	$21.84
Rate for Payer: Kaiser Permanente Commercial	$46.80
Rate for Payer: Kaiser Permanente Medicaid	$26.52
Rate for Payer: Kaiser Permanente Medicare	$21.84
Rate for Payer: MDX Hawaii PPO	$50.44
Rate for Payer: Ohana Health Plan Medicaid	$21.84
Rate for Payer: Ohana Health Plan Medicare	$21.84
Rate for Payer: UnitedHealthcare Medicaid	$2.57
Rate for Payer: UnitedHealthcare Medicare	$21.84
Rate for Payer: University Health Alliance Commercial	$4.81

Know your out-of-pocket cost for care.

All Charges