Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

amikacin 1000 mg / 4 mL Soln [KMC]

Facility

$13.24

Service Code	HCPCS J0278
Hospital Revenue Code	636
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$12.84
Rate for Payer: Cash Price	$8.61
Rate for Payer: Health Management Network Commercial	$11.25
Rate for Payer: Kaiser Permanente Commercial	$11.92
Rate for Payer: MDX Hawaii PPO	$12.84

amikacin 1000 mg / 4 mL Soln [KMC]

Facility

$13.24

Service Code	HCPCS J0278
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$12.84
Rate for Payer: AlohaCare Medicaid	$6.62
Rate for Payer: AlohaCare Medicare	$5.56
Rate for Payer: Cash Price	$8.61
Rate for Payer: Cash Price	$8.61
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.18
Rate for Payer: Devoted Health Medicare	$5.56
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Medicare	$5.56
Rate for Payer: Hawaii Western Management Group Commercial	$12.58
Rate for Payer: Health Management Network Commercial	$11.25
Rate for Payer: Humana Medicare	$5.56
Rate for Payer: Kaiser Permanente Commercial	$11.92
Rate for Payer: Kaiser Permanente Medicaid	$6.75
Rate for Payer: Kaiser Permanente Medicare	$5.56
Rate for Payer: MDX Hawaii PPO	$12.84
Rate for Payer: Ohana Health Plan Medicaid	$5.56
Rate for Payer: Ohana Health Plan Medicare	$5.56
Rate for Payer: UnitedHealthcare Medicaid	$7.94
Rate for Payer: UnitedHealthcare Medicare	$5.56
Rate for Payer: University Health Alliance Commercial	$9.65

amikacin 500 mg/2 mL IV Sol [KMC]

Facility

$26.98

Service Code	HCPCS J0278
Hospital Revenue Code	636
Min. Negotiated Rate	$22.93
Max. Negotiated Rate	$26.17
Rate for Payer: Cash Price	$17.54
Rate for Payer: Health Management Network Commercial	$22.93
Rate for Payer: Kaiser Permanente Commercial	$24.28
Rate for Payer: MDX Hawaii PPO	$26.17

amikacin 500 mg/2 mL IV Sol [KMC]

Facility

$26.98

Service Code	HCPCS J0278
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$26.17
Rate for Payer: AlohaCare Medicaid	$13.49
Rate for Payer: AlohaCare Medicare	$11.33
Rate for Payer: Cash Price	$17.54
Rate for Payer: Cash Price	$17.54
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$24.82
Rate for Payer: Devoted Health Medicare	$11.33
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Medicare	$11.33
Rate for Payer: Hawaii Western Management Group Commercial	$25.63
Rate for Payer: Health Management Network Commercial	$22.93
Rate for Payer: Humana Medicare	$11.33
Rate for Payer: Kaiser Permanente Commercial	$24.28
Rate for Payer: Kaiser Permanente Medicaid	$13.76
Rate for Payer: Kaiser Permanente Medicare	$11.33
Rate for Payer: MDX Hawaii PPO	$26.17
Rate for Payer: Ohana Health Plan Medicaid	$11.33
Rate for Payer: Ohana Health Plan Medicare	$11.33
Rate for Payer: UnitedHealthcare Medicaid	$16.19
Rate for Payer: UnitedHealthcare Medicare	$11.33
Rate for Payer: University Health Alliance Commercial	$19.67

Amikacin (Trough) DLS

Facility

$150.00

Service Code	HCPCS 80150
Hospital Charge Code	422801505
Hospital Revenue Code	301
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: MDX Hawaii PPO	$145.50

Amikacin (Trough) DLS

Facility

$150.00

Service Code	HCPCS 80150
Hospital Charge Code	422801505
Hospital Revenue Code	301
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$75.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$138.00
Rate for Payer: Devoted Health Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.83
Rate for Payer: Hawaii Medical Service Association Commercial	$18.85
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$15.08
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$20.83
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$38.96

aMILoride 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00574029201
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

aMILoride 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00574029201
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

aminocaproic acid 500 mg Tab [KMC]

Facility

$89.61

Service Code	NDC 62559022530
Hospital Revenue Code	250
Min. Negotiated Rate	$76.17
Max. Negotiated Rate	$86.92
Rate for Payer: Cash Price	$58.25
Rate for Payer: Health Management Network Commercial	$76.17
Rate for Payer: Kaiser Permanente Commercial	$80.65
Rate for Payer: MDX Hawaii PPO	$86.92

aminocaproic acid 500 mg Tab [KMC]

Facility

$89.61

Service Code	NDC 62559022530
Hospital Revenue Code	250
Min. Negotiated Rate	$37.64
Max. Negotiated Rate	$86.92
Rate for Payer: AlohaCare Medicaid	$44.80
Rate for Payer: AlohaCare Medicare	$37.64
Rate for Payer: Cash Price	$58.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$82.44
Rate for Payer: Devoted Health Medicare	$37.64
Rate for Payer: Hawaii Medical Service Association Medicare	$37.64
Rate for Payer: Hawaii Western Management Group Commercial	$85.13
Rate for Payer: Health Management Network Commercial	$76.17
Rate for Payer: Humana Medicare	$37.64
Rate for Payer: Kaiser Permanente Commercial	$80.65
Rate for Payer: Kaiser Permanente Medicaid	$45.70
Rate for Payer: Kaiser Permanente Medicare	$37.64
Rate for Payer: MDX Hawaii PPO	$86.92
Rate for Payer: Ohana Health Plan Medicaid	$37.64
Rate for Payer: Ohana Health Plan Medicare	$37.64
Rate for Payer: UnitedHealthcare Medicaid	$53.77
Rate for Payer: UnitedHealthcare Medicare	$37.64
Rate for Payer: University Health Alliance Commercial	$65.32

amiodarone 150 mg/3 mL IV Sol [KMC]

Facility

$5.81

Service Code	HCPCS J0282
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$5.64
Rate for Payer: AlohaCare Medicaid	$2.90
Rate for Payer: AlohaCare Medicare	$2.44
Rate for Payer: Cash Price	$3.78
Rate for Payer: Cash Price	$3.78
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.35
Rate for Payer: Devoted Health Medicare	$2.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2.44
Rate for Payer: Hawaii Western Management Group Commercial	$5.52
Rate for Payer: Health Management Network Commercial	$4.94
Rate for Payer: Humana Medicare	$2.44
Rate for Payer: Kaiser Permanente Commercial	$5.23
Rate for Payer: Kaiser Permanente Medicaid	$2.96
Rate for Payer: Kaiser Permanente Medicare	$2.44
Rate for Payer: MDX Hawaii PPO	$5.64
Rate for Payer: Ohana Health Plan Medicaid	$2.44
Rate for Payer: Ohana Health Plan Medicare	$2.44
Rate for Payer: UnitedHealthcare Medicaid	$3.49
Rate for Payer: UnitedHealthcare Medicare	$2.44
Rate for Payer: University Health Alliance Commercial	$4.23

amiodarone 150 mg/3 mL IV Sol [KMC]

Facility

$5.81

Service Code	HCPCS J0282
Hospital Revenue Code	636
Min. Negotiated Rate	$4.94
Max. Negotiated Rate	$5.64
Rate for Payer: Cash Price	$3.78
Rate for Payer: Health Management Network Commercial	$4.94
Rate for Payer: Kaiser Permanente Commercial	$5.23
Rate for Payer: MDX Hawaii PPO	$5.64

amiodarone 200 mg Tab [KMC]

Facility

$13.16

Service Code	NDC 51079090620
Hospital Revenue Code	250
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$12.77
Rate for Payer: Cash Price	$8.55
Rate for Payer: Health Management Network Commercial	$11.19
Rate for Payer: Kaiser Permanente Commercial	$11.84
Rate for Payer: MDX Hawaii PPO	$12.77

amiodarone 200 mg Tab [KMC]

Facility

$13.16

Service Code	NDC 51079090620
Hospital Revenue Code	250
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$12.77
Rate for Payer: AlohaCare Medicaid	$6.58
Rate for Payer: AlohaCare Medicare	$5.53
Rate for Payer: Cash Price	$8.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.11
Rate for Payer: Devoted Health Medicare	$5.53
Rate for Payer: Hawaii Medical Service Association Medicare	$5.53
Rate for Payer: Hawaii Western Management Group Commercial	$12.50
Rate for Payer: Health Management Network Commercial	$11.19
Rate for Payer: Humana Medicare	$5.53
Rate for Payer: Kaiser Permanente Commercial	$11.84
Rate for Payer: Kaiser Permanente Medicaid	$6.71
Rate for Payer: Kaiser Permanente Medicare	$5.53
Rate for Payer: MDX Hawaii PPO	$12.77
Rate for Payer: Ohana Health Plan Medicaid	$5.53
Rate for Payer: Ohana Health Plan Medicare	$5.53
Rate for Payer: UnitedHealthcare Medicaid	$7.90
Rate for Payer: UnitedHealthcare Medicare	$5.53
Rate for Payer: University Health Alliance Commercial	$9.59

amitriptyline 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 16714025701
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

amitriptyline 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 16714025701
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

amitriptyline 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 29300042001
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

amitriptyline 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 29300042001
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

amLODIPine 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 76282023910
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

amLODIPine 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 76282023910
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

amLODIPine 5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
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

amLODIPine 5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
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

amlodipine-benazepril 10 mg-40 mg Cap [KMC]

Facility

$19.59

Service Code	NDC 65862058701
Hospital Revenue Code	250
Min. Negotiated Rate	$16.65
Max. Negotiated Rate	$19.00
Rate for Payer: Cash Price	$12.73
Rate for Payer: Health Management Network Commercial	$16.65
Rate for Payer: Kaiser Permanente Commercial	$17.63
Rate for Payer: MDX Hawaii PPO	$19.00

amlodipine-benazepril 10 mg-40 mg Cap [KMC]

Facility

$19.59

Service Code	NDC 65862058701
Hospital Revenue Code	250
Min. Negotiated Rate	$8.23
Max. Negotiated Rate	$19.00
Rate for Payer: AlohaCare Medicaid	$9.79
Rate for Payer: AlohaCare Medicare	$8.23
Rate for Payer: Cash Price	$12.73
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$18.02
Rate for Payer: Devoted Health Medicare	$8.23
Rate for Payer: Hawaii Medical Service Association Medicare	$8.23
Rate for Payer: Hawaii Western Management Group Commercial	$18.61
Rate for Payer: Health Management Network Commercial	$16.65
Rate for Payer: Humana Medicare	$8.23
Rate for Payer: Kaiser Permanente Commercial	$17.63
Rate for Payer: Kaiser Permanente Medicaid	$9.99
Rate for Payer: Kaiser Permanente Medicare	$8.23
Rate for Payer: MDX Hawaii PPO	$19.00
Rate for Payer: Ohana Health Plan Medicaid	$8.23
Rate for Payer: Ohana Health Plan Medicare	$8.23
Rate for Payer: UnitedHealthcare Medicaid	$11.75
Rate for Payer: UnitedHealthcare Medicare	$8.23
Rate for Payer: University Health Alliance Commercial	$14.28

amlodipine-benazepril 5 mg-10 mg Cap[KMC]

Facility

$10.83

Service Code	NDC 65862058301
Hospital Revenue Code	250
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$10.51
Rate for Payer: Cash Price	$7.04
Rate for Payer: Health Management Network Commercial	$9.21
Rate for Payer: Kaiser Permanente Commercial	$9.75
Rate for Payer: MDX Hawaii PPO	$10.51

Know your out-of-pocket cost for care.

All Charges