Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

mometasone-formoterol 200-5 mcg inhaler [KMC]

Facility

$114.96

Service Code	NDC 00085461001
Hospital Revenue Code	250
Min. Negotiated Rate	$48.28
Max. Negotiated Rate	$111.51
Rate for Payer: AlohaCare Medicaid	$57.48
Rate for Payer: AlohaCare Medicare	$48.28
Rate for Payer: Cash Price	$74.72
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$105.76
Rate for Payer: Devoted Health Medicare	$48.28
Rate for Payer: Hawaii Medical Service Association Medicare	$48.28
Rate for Payer: Hawaii Western Management Group Commercial	$109.21
Rate for Payer: Health Management Network Commercial	$97.72
Rate for Payer: Humana Medicare	$48.28
Rate for Payer: Kaiser Permanente Commercial	$103.46
Rate for Payer: Kaiser Permanente Medicaid	$58.63
Rate for Payer: Kaiser Permanente Medicare	$48.28
Rate for Payer: MDX Hawaii PPO	$111.51
Rate for Payer: Ohana Health Plan Medicaid	$48.28
Rate for Payer: Ohana Health Plan Medicare	$48.28
Rate for Payer: UnitedHealthcare Medicaid	$68.98
Rate for Payer: UnitedHealthcare Medicare	$48.28
Rate for Payer: University Health Alliance Commercial	$83.79

mometasone nasal 50 mcg spray [KMC]

Facility

$62.81

Service Code	NDC 65162089129
Hospital Revenue Code	250
Min. Negotiated Rate	$26.38
Max. Negotiated Rate	$60.93
Rate for Payer: AlohaCare Medicaid	$31.41
Rate for Payer: AlohaCare Medicare	$26.38
Rate for Payer: Cash Price	$40.83
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$57.79
Rate for Payer: Devoted Health Medicare	$26.38
Rate for Payer: Hawaii Medical Service Association Medicare	$26.38
Rate for Payer: Hawaii Western Management Group Commercial	$59.67
Rate for Payer: Health Management Network Commercial	$53.39
Rate for Payer: Humana Medicare	$26.38
Rate for Payer: Kaiser Permanente Commercial	$56.53
Rate for Payer: Kaiser Permanente Medicaid	$32.03
Rate for Payer: Kaiser Permanente Medicare	$26.38
Rate for Payer: MDX Hawaii PPO	$60.93
Rate for Payer: Ohana Health Plan Medicaid	$26.38
Rate for Payer: Ohana Health Plan Medicare	$26.38
Rate for Payer: UnitedHealthcare Medicaid	$37.69
Rate for Payer: UnitedHealthcare Medicare	$26.38
Rate for Payer: University Health Alliance Commercial	$45.78

mometasone nasal 50 mcg spray [KMC]

Facility

$62.81

Service Code	NDC 65162089129
Hospital Revenue Code	250
Min. Negotiated Rate	$53.39
Max. Negotiated Rate	$60.93
Rate for Payer: Cash Price	$40.83
Rate for Payer: Health Management Network Commercial	$53.39
Rate for Payer: Kaiser Permanente Commercial	$56.53
Rate for Payer: MDX Hawaii PPO	$60.93

MONITORING OF INTERSTITIAL FLUID PRESSURE IN DETEC

Facility

$816.00

Service Code	HCPCS 20950
Hospital Charge Code	440209500
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$408.00
Rate for Payer: AlohaCare Medicare	$342.72
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$750.72
Rate for Payer: Devoted Health Medicare	$342.72
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$342.72
Rate for Payer: Hawaii Western Management Group Commercial	$775.20
Rate for Payer: Health Management Network Commercial	$693.60
Rate for Payer: Humana Medicare	$342.72
Rate for Payer: Kaiser Permanente Commercial	$734.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$342.72
Rate for Payer: MDX Hawaii PPO	$791.52
Rate for Payer: Ohana Health Plan Medicaid	$342.72
Rate for Payer: Ohana Health Plan Medicare	$342.72
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$342.72
Rate for Payer: University Health Alliance Commercial	$594.78

MONITORING OF INTERSTITIAL FLUID PRESSURE IN DETEC

Facility

$816.00

Service Code	HCPCS 20950
Hospital Charge Code	440209500
Hospital Revenue Code	450
Min. Negotiated Rate	$693.60
Max. Negotiated Rate	$791.52
Rate for Payer: Cash Price	$530.40
Rate for Payer: Health Management Network Commercial	$693.60
Rate for Payer: Kaiser Permanente Commercial	$734.40
Rate for Payer: MDX Hawaii PPO	$791.52

Mono Screen 1

Facility

$82.00

Service Code	HCPCS 86308
Hospital Charge Code	422863080
Hospital Revenue Code	302
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$79.54
Rate for Payer: AlohaCare Medicaid	$41.00
Rate for Payer: AlohaCare Medicare	$34.44
Rate for Payer: Cash Price	$53.30
Rate for Payer: Cash Price	$53.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$75.44
Rate for Payer: Devoted Health Medicare	$34.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$34.44
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Humana Medicare	$34.44
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: Kaiser Permanente Medicare	$34.44
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: Ohana Health Plan Medicaid	$34.44
Rate for Payer: Ohana Health Plan Medicare	$34.44
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$34.44
Rate for Payer: University Health Alliance Commercial	$13.38

Mono Screen 1

Facility

$82.00

Service Code	HCPCS 86308
Hospital Charge Code	422863080
Hospital Revenue Code	302
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$53.30
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: MDX Hawaii PPO	$79.54

Mono Screen 7

Facility

$82.00

Service Code	HCPCS 86308
Hospital Charge Code	422863080
Hospital Revenue Code	302
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$79.54
Rate for Payer: AlohaCare Medicaid	$41.00
Rate for Payer: AlohaCare Medicare	$34.44
Rate for Payer: Cash Price	$53.30
Rate for Payer: Cash Price	$53.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$75.44
Rate for Payer: Devoted Health Medicare	$34.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$34.44
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Humana Medicare	$34.44
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: Kaiser Permanente Medicare	$34.44
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: Ohana Health Plan Medicaid	$34.44
Rate for Payer: Ohana Health Plan Medicare	$34.44
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$34.44
Rate for Payer: University Health Alliance Commercial	$13.38

Mono Screen 7

Facility

$82.00

Service Code	HCPCS 86308
Hospital Charge Code	422863080
Hospital Revenue Code	302
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$53.30
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: MDX Hawaii PPO	$79.54

montelukast 10 mg Tab [KMC]

Facility

$22.62

Service Code	NDC 29300022019
Hospital Revenue Code	250
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$21.94
Rate for Payer: AlohaCare Medicaid	$11.31
Rate for Payer: AlohaCare Medicare	$9.50
Rate for Payer: Cash Price	$14.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$20.81
Rate for Payer: Devoted Health Medicare	$9.50
Rate for Payer: Hawaii Medical Service Association Medicare	$9.50
Rate for Payer: Hawaii Western Management Group Commercial	$21.49
Rate for Payer: Health Management Network Commercial	$19.23
Rate for Payer: Humana Medicare	$9.50
Rate for Payer: Kaiser Permanente Commercial	$20.36
Rate for Payer: Kaiser Permanente Medicaid	$11.54
Rate for Payer: Kaiser Permanente Medicare	$9.50
Rate for Payer: MDX Hawaii PPO	$21.94
Rate for Payer: Ohana Health Plan Medicaid	$9.50
Rate for Payer: Ohana Health Plan Medicare	$9.50
Rate for Payer: UnitedHealthcare Medicaid	$13.57
Rate for Payer: UnitedHealthcare Medicare	$9.50
Rate for Payer: University Health Alliance Commercial	$16.49

montelukast 10 mg Tab [KMC]

Facility

$22.62

Service Code	NDC 29300022019
Hospital Revenue Code	250
Min. Negotiated Rate	$19.23
Max. Negotiated Rate	$21.94
Rate for Payer: Cash Price	$14.70
Rate for Payer: Health Management Network Commercial	$19.23
Rate for Payer: Kaiser Permanente Commercial	$20.36
Rate for Payer: MDX Hawaii PPO	$21.94

MORGAN LENS

Facility

$17.00

Hospital Charge Code	8182
Hospital Revenue Code	270
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$7.14
Rate for Payer: Cash Price	$11.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.64
Rate for Payer: Devoted Health Medicare	$7.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7.14
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$7.14
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$7.14
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$7.14
Rate for Payer: Ohana Health Plan Medicare	$7.14
Rate for Payer: UnitedHealthcare Medicare	$7.14
Rate for Payer: University Health Alliance Commercial	$12.39

MORGAN LENS

Facility

$17.00

Hospital Charge Code	8182
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

morphine 100 mg ER Tab [KMC]

Facility

$36.80

Service Code	NDC 00406839001
Hospital Revenue Code	250
Min. Negotiated Rate	$31.28
Max. Negotiated Rate	$35.70
Rate for Payer: Cash Price	$23.92
Rate for Payer: Health Management Network Commercial	$31.28
Rate for Payer: Kaiser Permanente Commercial	$33.12
Rate for Payer: MDX Hawaii PPO	$35.70

morphine 100 mg ER Tab [KMC]

Facility

$36.80

Service Code	NDC 00406839001
Hospital Revenue Code	250
Min. Negotiated Rate	$15.46
Max. Negotiated Rate	$35.70
Rate for Payer: AlohaCare Medicaid	$18.40
Rate for Payer: AlohaCare Medicare	$15.46
Rate for Payer: Cash Price	$23.92
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.86
Rate for Payer: Devoted Health Medicare	$15.46
Rate for Payer: Hawaii Medical Service Association Medicare	$15.46
Rate for Payer: Hawaii Western Management Group Commercial	$34.96
Rate for Payer: Health Management Network Commercial	$31.28
Rate for Payer: Humana Medicare	$15.46
Rate for Payer: Kaiser Permanente Commercial	$33.12
Rate for Payer: Kaiser Permanente Medicaid	$18.77
Rate for Payer: Kaiser Permanente Medicare	$15.46
Rate for Payer: MDX Hawaii PPO	$35.70
Rate for Payer: Ohana Health Plan Medicaid	$15.46
Rate for Payer: Ohana Health Plan Medicare	$15.46
Rate for Payer: UnitedHealthcare Medicaid	$22.08
Rate for Payer: UnitedHealthcare Medicare	$15.46
Rate for Payer: University Health Alliance Commercial	$26.82

morphine 15 mg ER Tab [KMC]

Facility

$6.70

Service Code	NDC 63304045001
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$6.50
Rate for Payer: Cash Price	$4.36
Rate for Payer: Health Management Network Commercial	$5.70
Rate for Payer: Kaiser Permanente Commercial	$6.03
Rate for Payer: MDX Hawaii PPO	$6.50

morphine 15 mg ER Tab [KMC]

Facility

$6.70

Service Code	NDC 63304045001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$6.50
Rate for Payer: AlohaCare Medicaid	$3.35
Rate for Payer: AlohaCare Medicare	$2.81
Rate for Payer: Cash Price	$4.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.16
Rate for Payer: Devoted Health Medicare	$2.81
Rate for Payer: Hawaii Medical Service Association Medicare	$2.81
Rate for Payer: Hawaii Western Management Group Commercial	$6.37
Rate for Payer: Health Management Network Commercial	$5.70
Rate for Payer: Humana Medicare	$2.81
Rate for Payer: Kaiser Permanente Commercial	$6.03
Rate for Payer: Kaiser Permanente Medicaid	$3.42
Rate for Payer: Kaiser Permanente Medicare	$2.81
Rate for Payer: MDX Hawaii PPO	$6.50
Rate for Payer: Ohana Health Plan Medicaid	$2.81
Rate for Payer: Ohana Health Plan Medicare	$2.81
Rate for Payer: UnitedHealthcare Medicaid	$4.02
Rate for Payer: UnitedHealthcare Medicare	$2.81
Rate for Payer: University Health Alliance Commercial	$4.88

morphine 15 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00832027311
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

morphine 15 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00832027311
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

morphine 20 mg/mL Oral Concentrate [KMC]

Facility

$3.36

Service Code	NDC 00054040444
Hospital Revenue Code	250
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$3.26
Rate for Payer: Cash Price	$2.18
Rate for Payer: Health Management Network Commercial	$2.86
Rate for Payer: Kaiser Permanente Commercial	$3.02
Rate for Payer: MDX Hawaii PPO	$3.26

morphine 20 mg/mL Oral Concentrate [KMC]

Facility

$3.36

Service Code	NDC 00054040444
Hospital Revenue Code	250
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$3.26
Rate for Payer: AlohaCare Medicaid	$1.68
Rate for Payer: AlohaCare Medicare	$1.41
Rate for Payer: Cash Price	$2.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.09
Rate for Payer: Devoted Health Medicare	$1.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.19
Rate for Payer: Health Management Network Commercial	$2.86
Rate for Payer: Humana Medicare	$1.41
Rate for Payer: Kaiser Permanente Commercial	$3.02
Rate for Payer: Kaiser Permanente Medicaid	$1.71
Rate for Payer: Kaiser Permanente Medicare	$1.41
Rate for Payer: MDX Hawaii PPO	$3.26
Rate for Payer: Ohana Health Plan Medicaid	$1.41
Rate for Payer: Ohana Health Plan Medicare	$1.41
Rate for Payer: UnitedHealthcare Medicaid	$2.02
Rate for Payer: UnitedHealthcare Medicare	$1.41
Rate for Payer: University Health Alliance Commercial	$2.45

morphine 30 mg ER Tab [KMC]

Facility

$12.69

Service Code	NDC 63304045101
Hospital Revenue Code	250
Min. Negotiated Rate	$10.79
Max. Negotiated Rate	$12.31
Rate for Payer: Cash Price	$8.25
Rate for Payer: Health Management Network Commercial	$10.79
Rate for Payer: Kaiser Permanente Commercial	$11.42
Rate for Payer: MDX Hawaii PPO	$12.31

morphine 30 mg ER Tab [KMC]

Facility

$12.69

Service Code	NDC 63304045101
Hospital Revenue Code	250
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$12.31
Rate for Payer: AlohaCare Medicaid	$6.34
Rate for Payer: AlohaCare Medicare	$5.33
Rate for Payer: Cash Price	$8.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.67
Rate for Payer: Devoted Health Medicare	$5.33
Rate for Payer: Hawaii Medical Service Association Medicare	$5.33
Rate for Payer: Hawaii Western Management Group Commercial	$12.06
Rate for Payer: Health Management Network Commercial	$10.79
Rate for Payer: Humana Medicare	$5.33
Rate for Payer: Kaiser Permanente Commercial	$11.42
Rate for Payer: Kaiser Permanente Medicaid	$6.47
Rate for Payer: Kaiser Permanente Medicare	$5.33
Rate for Payer: MDX Hawaii PPO	$12.31
Rate for Payer: Ohana Health Plan Medicaid	$5.33
Rate for Payer: Ohana Health Plan Medicare	$5.33
Rate for Payer: UnitedHealthcare Medicaid	$7.61
Rate for Payer: UnitedHealthcare Medicare	$5.33
Rate for Payer: University Health Alliance Commercial	$9.25

morphine 30 mg Tab [KMC]

Facility

$3.35

Service Code	NDC 00832027411
Hospital Revenue Code	250
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$2.18
Rate for Payer: Health Management Network Commercial	$2.85
Rate for Payer: Kaiser Permanente Commercial	$3.02
Rate for Payer: MDX Hawaii PPO	$3.25

morphine 30 mg Tab [KMC]

Facility

$3.35

Service Code	NDC 00832027411
Hospital Revenue Code	250
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$3.25
Rate for Payer: AlohaCare Medicaid	$1.68
Rate for Payer: AlohaCare Medicare	$1.41
Rate for Payer: Cash Price	$2.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.08
Rate for Payer: Devoted Health Medicare	$1.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.18
Rate for Payer: Health Management Network Commercial	$2.85
Rate for Payer: Humana Medicare	$1.41
Rate for Payer: Kaiser Permanente Commercial	$3.02
Rate for Payer: Kaiser Permanente Medicaid	$1.71
Rate for Payer: Kaiser Permanente Medicare	$1.41
Rate for Payer: MDX Hawaii PPO	$3.25
Rate for Payer: Ohana Health Plan Medicaid	$1.41
Rate for Payer: Ohana Health Plan Medicare	$1.41
Rate for Payer: UnitedHealthcare Medicaid	$2.01
Rate for Payer: UnitedHealthcare Medicare	$1.41
Rate for Payer: University Health Alliance Commercial	$2.44

Know your out-of-pocket cost for care.

All Charges