Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Misc Sensitivites. By E-test DLS

Facility

$52.00

Service Code	HCPCS 87181
Hospital Charge Code	422871815
Hospital Revenue Code	306
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$50.44
Rate for Payer: Cash Price	$33.80
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Kaiser Permanente Commercial	$46.80
Rate for Payer: MDX Hawaii PPO	$50.44

miSOPROStol 100 mcg Tab [KMC]

Facility

$3.92

Service Code	NDC 43386016006
Hospital Revenue Code	250
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$2.55
Rate for Payer: Health Management Network Commercial	$3.33
Rate for Payer: Kaiser Permanente Commercial	$3.53
Rate for Payer: MDX Hawaii PPO	$3.80

miSOPROStol 100 mcg Tab [KMC]

Facility

$3.92

Service Code	NDC 43386016006
Hospital Revenue Code	250
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$3.80
Rate for Payer: AlohaCare Medicaid	$1.96
Rate for Payer: AlohaCare Medicare	$1.65
Rate for Payer: Cash Price	$2.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.61
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.65
Rate for Payer: Hawaii Western Management Group Commercial	$3.72
Rate for Payer: Health Management Network Commercial	$3.33
Rate for Payer: Humana Medicare	$1.65
Rate for Payer: Kaiser Permanente Commercial	$3.53
Rate for Payer: Kaiser Permanente Medicaid	$2.00
Rate for Payer: Kaiser Permanente Medicare	$1.65
Rate for Payer: MDX Hawaii PPO	$3.80
Rate for Payer: Ohana Health Plan Medicaid	$1.65
Rate for Payer: Ohana Health Plan Medicare	$1.65
Rate for Payer: UnitedHealthcare Medicaid	$2.35
Rate for Payer: UnitedHealthcare Medicare	$1.65
Rate for Payer: University Health Alliance Commercial	$2.86

misoprostol 200 mcg Tab [KMC]

Facility

$4.80

Service Code	NDC 59762500801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$4.66
Rate for Payer: AlohaCare Medicaid	$2.40
Rate for Payer: AlohaCare Medicare	$2.02
Rate for Payer: Cash Price	$3.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.42
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	$4.56
Rate for Payer: Health Management Network Commercial	$4.08
Rate for Payer: Humana Medicare	$2.02
Rate for Payer: Kaiser Permanente Commercial	$4.32
Rate for Payer: Kaiser Permanente Medicaid	$2.45
Rate for Payer: Kaiser Permanente Medicare	$2.02
Rate for Payer: MDX Hawaii PPO	$4.66
Rate for Payer: Ohana Health Plan Medicaid	$2.02
Rate for Payer: Ohana Health Plan Medicare	$2.02
Rate for Payer: UnitedHealthcare Medicaid	$2.88
Rate for Payer: UnitedHealthcare Medicare	$2.02
Rate for Payer: University Health Alliance Commercial	$3.50

misoprostol 200 mcg Tab [KMC]

Facility

$4.80

Service Code	NDC 59762500801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$4.66
Rate for Payer: Cash Price	$3.12
Rate for Payer: Health Management Network Commercial	$4.08
Rate for Payer: Kaiser Permanente Commercial	$4.32
Rate for Payer: MDX Hawaii PPO	$4.66

MISTY T NEBULIZER

Facility

$3.00

Hospital Charge Code	8181
Hospital Revenue Code	270
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

MISTY T NEBULIZER

Facility

$3.00

Hospital Charge Code	8181
Hospital Revenue Code	270
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

MMR II Vaccine [KMC]

Facility

$408.31

Service Code	NDC 00006468100
Hospital Revenue Code	250
Min. Negotiated Rate	$171.49
Max. Negotiated Rate	$396.06
Rate for Payer: AlohaCare Medicaid	$204.16
Rate for Payer: AlohaCare Medicare	$171.49
Rate for Payer: Cash Price	$265.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$375.65
Rate for Payer: Devoted Health Medicare	$171.49
Rate for Payer: Hawaii Medical Service Association Medicare	$171.49
Rate for Payer: Hawaii Western Management Group Commercial	$387.89
Rate for Payer: Health Management Network Commercial	$347.06
Rate for Payer: Humana Medicare	$171.49
Rate for Payer: Kaiser Permanente Commercial	$367.48
Rate for Payer: Kaiser Permanente Medicaid	$208.24
Rate for Payer: Kaiser Permanente Medicare	$171.49
Rate for Payer: MDX Hawaii PPO	$396.06
Rate for Payer: Ohana Health Plan Medicaid	$171.49
Rate for Payer: Ohana Health Plan Medicare	$171.49
Rate for Payer: UnitedHealthcare Medicaid	$244.99
Rate for Payer: UnitedHealthcare Medicare	$171.49
Rate for Payer: University Health Alliance Commercial	$297.62

MMR II Vaccine [KMC]

Facility

$408.31

Service Code	NDC 00006468100
Hospital Revenue Code	250
Min. Negotiated Rate	$347.06
Max. Negotiated Rate	$396.06
Rate for Payer: Cash Price	$265.40
Rate for Payer: Health Management Network Commercial	$347.06
Rate for Payer: Kaiser Permanente Commercial	$367.48
Rate for Payer: MDX Hawaii PPO	$396.06

MOBILITY CURRENT STATUS

Professional

Both

$0.01

Service Code	HCPCS G8978
Hospital Revenue Code	420
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

MOBILITY CURRENT STATUS Physical

Facility

$1.00

Service Code	HCPCS G8978 GP
Hospital Charge Code	426G89780
Hospital Revenue Code	420
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

MOBILITY CURRENT STATUS Physical

Facility

$1.00

Service Code	HCPCS G8978 GP
Hospital Charge Code	426G89780
Hospital Revenue Code	420
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

MOBILITY D/C STATUS

Professional

Both

$0.01

Service Code	HCPCS G8980
Hospital Revenue Code	420
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

MOBILITY D/C STATUS Physical

Facility

$1.00

Service Code	HCPCS G8980 GP
Hospital Charge Code	426G89800
Hospital Revenue Code	420
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

MOBILITY D/C STATUS Physical

Facility

$1.00

Service Code	HCPCS G8980 GP
Hospital Charge Code	426G89800
Hospital Revenue Code	420
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

MOBILITY GOAL STATUS

Professional

Both

$0.01

Service Code	HCPCS G8979
Hospital Revenue Code	420
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

modafinil 100 mg Tab [KMC]

Facility

$88.27

Service Code	NDC 49884053411
Hospital Revenue Code	250
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$85.62
Rate for Payer: AlohaCare Medicaid	$44.13
Rate for Payer: AlohaCare Medicare	$37.07
Rate for Payer: Cash Price	$57.38
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$81.21
Rate for Payer: Devoted Health Medicare	$37.07
Rate for Payer: Hawaii Medical Service Association Medicare	$37.07
Rate for Payer: Hawaii Western Management Group Commercial	$83.86
Rate for Payer: Health Management Network Commercial	$75.03
Rate for Payer: Humana Medicare	$37.07
Rate for Payer: Kaiser Permanente Commercial	$79.44
Rate for Payer: Kaiser Permanente Medicaid	$45.02
Rate for Payer: Kaiser Permanente Medicare	$37.07
Rate for Payer: MDX Hawaii PPO	$85.62
Rate for Payer: Ohana Health Plan Medicaid	$37.07
Rate for Payer: Ohana Health Plan Medicare	$37.07
Rate for Payer: UnitedHealthcare Medicaid	$52.96
Rate for Payer: UnitedHealthcare Medicare	$37.07
Rate for Payer: University Health Alliance Commercial	$64.34

modafinil 100 mg Tab [KMC]

Facility

$88.27

Service Code	NDC 49884053411
Hospital Revenue Code	250
Min. Negotiated Rate	$75.03
Max. Negotiated Rate	$85.62
Rate for Payer: Cash Price	$57.38
Rate for Payer: Health Management Network Commercial	$75.03
Rate for Payer: Kaiser Permanente Commercial	$79.44
Rate for Payer: MDX Hawaii PPO	$85.62

modafinil 200 mg Tab

Facility

$159.78

Service Code	NDC 65862060230
Hospital Revenue Code	250
Min. Negotiated Rate	$67.11
Max. Negotiated Rate	$154.99
Rate for Payer: AlohaCare Medicaid	$79.89
Rate for Payer: AlohaCare Medicare	$67.11
Rate for Payer: Cash Price	$103.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$147.00
Rate for Payer: Devoted Health Medicare	$67.11
Rate for Payer: Hawaii Medical Service Association Medicare	$67.11
Rate for Payer: Hawaii Western Management Group Commercial	$151.79
Rate for Payer: Health Management Network Commercial	$135.81
Rate for Payer: Humana Medicare	$67.11
Rate for Payer: Kaiser Permanente Commercial	$143.80
Rate for Payer: Kaiser Permanente Medicaid	$81.49
Rate for Payer: Kaiser Permanente Medicare	$67.11
Rate for Payer: MDX Hawaii PPO	$154.99
Rate for Payer: Ohana Health Plan Medicaid	$67.11
Rate for Payer: Ohana Health Plan Medicare	$67.11
Rate for Payer: UnitedHealthcare Medicaid	$95.87
Rate for Payer: UnitedHealthcare Medicare	$67.11
Rate for Payer: University Health Alliance Commercial	$116.46

modafinil 200 mg Tab

Facility

$159.78

Service Code	NDC 65862060230
Hospital Revenue Code	250
Min. Negotiated Rate	$135.81
Max. Negotiated Rate	$154.99
Rate for Payer: Cash Price	$103.86
Rate for Payer: Health Management Network Commercial	$135.81
Rate for Payer: Kaiser Permanente Commercial	$143.80
Rate for Payer: MDX Hawaii PPO	$154.99

mometasone 0.1% Cream [KMC]

Facility

$7.78

Service Code	NDC 68462019217
Hospital Revenue Code	250
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$7.55
Rate for Payer: AlohaCare Medicaid	$3.89
Rate for Payer: AlohaCare Medicare	$3.27
Rate for Payer: Cash Price	$5.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.16
Rate for Payer: Devoted Health Medicare	$3.27
Rate for Payer: Hawaii Medical Service Association Medicare	$3.27
Rate for Payer: Hawaii Western Management Group Commercial	$7.39
Rate for Payer: Health Management Network Commercial	$6.61
Rate for Payer: Humana Medicare	$3.27
Rate for Payer: Kaiser Permanente Commercial	$7.00
Rate for Payer: Kaiser Permanente Medicaid	$3.97
Rate for Payer: Kaiser Permanente Medicare	$3.27
Rate for Payer: MDX Hawaii PPO	$7.55
Rate for Payer: Ohana Health Plan Medicaid	$3.27
Rate for Payer: Ohana Health Plan Medicare	$3.27
Rate for Payer: UnitedHealthcare Medicaid	$4.67
Rate for Payer: UnitedHealthcare Medicare	$3.27
Rate for Payer: University Health Alliance Commercial	$5.67

mometasone 0.1% Cream [KMC]

Facility

$7.78

Service Code	NDC 68462019217
Hospital Revenue Code	250
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$7.55
Rate for Payer: Cash Price	$5.06
Rate for Payer: Health Management Network Commercial	$6.61
Rate for Payer: Kaiser Permanente Commercial	$7.00
Rate for Payer: MDX Hawaii PPO	$7.55

mometasone 0.1% Ointment [KMC]

Facility

$3.96

Service Code	NDC 45802011942
Hospital Revenue Code	250
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$3.84
Rate for Payer: AlohaCare Medicaid	$1.98
Rate for Payer: AlohaCare Medicare	$1.66
Rate for Payer: Cash Price	$2.57
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.64
Rate for Payer: Devoted Health Medicare	$1.66
Rate for Payer: Hawaii Medical Service Association Medicare	$1.66
Rate for Payer: Hawaii Western Management Group Commercial	$3.76
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Humana Medicare	$1.66
Rate for Payer: Kaiser Permanente Commercial	$3.56
Rate for Payer: Kaiser Permanente Medicaid	$2.02
Rate for Payer: Kaiser Permanente Medicare	$1.66
Rate for Payer: MDX Hawaii PPO	$3.84
Rate for Payer: Ohana Health Plan Medicaid	$1.66
Rate for Payer: Ohana Health Plan Medicare	$1.66
Rate for Payer: UnitedHealthcare Medicaid	$2.38
Rate for Payer: UnitedHealthcare Medicare	$1.66
Rate for Payer: University Health Alliance Commercial	$2.89

mometasone 0.1% Ointment [KMC]

Facility

$3.96

Service Code	NDC 45802011942
Hospital Revenue Code	250
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$3.84
Rate for Payer: Cash Price	$2.57
Rate for Payer: Health Management Network Commercial	$3.37
Rate for Payer: Kaiser Permanente Commercial	$3.56
Rate for Payer: MDX Hawaii PPO	$3.84

mometasone-formoterol 200-5 mcg inhaler [KMC]

Facility

$114.96

Service Code	NDC 00085461001
Hospital Revenue Code	250
Min. Negotiated Rate	$97.72
Max. Negotiated Rate	$111.51
Rate for Payer: Cash Price	$74.72
Rate for Payer: Health Management Network Commercial	$97.72
Rate for Payer: Kaiser Permanente Commercial	$103.46
Rate for Payer: MDX Hawaii PPO	$111.51

Know your out-of-pocket cost for care.

All Charges