Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

amlodipine-valsartan 10 mg-320 mg Tab [KMC]

Facility

$31.46

Service Code	NDC 00378172493
Hospital Revenue Code	250
Min. Negotiated Rate	$26.74
Max. Negotiated Rate	$30.52
Rate for Payer: Cash Price	$20.45
Rate for Payer: Health Management Network Commercial	$26.74
Rate for Payer: Kaiser Permanente Commercial	$28.31
Rate for Payer: MDX Hawaii PPO	$30.52

amlodipine-valsartan 10 mg-320 mg Tab [KMC]

Facility

$31.46

Service Code	NDC 00378172493
Hospital Revenue Code	250
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$30.52
Rate for Payer: AlohaCare Medicaid	$15.73
Rate for Payer: AlohaCare Medicare	$13.21
Rate for Payer: Cash Price	$20.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$28.94
Rate for Payer: Devoted Health Medicare	$13.21
Rate for Payer: Hawaii Medical Service Association Medicare	$13.21
Rate for Payer: Hawaii Western Management Group Commercial	$29.89
Rate for Payer: Health Management Network Commercial	$26.74
Rate for Payer: Humana Medicare	$13.21
Rate for Payer: Kaiser Permanente Commercial	$28.31
Rate for Payer: Kaiser Permanente Medicaid	$16.04
Rate for Payer: Kaiser Permanente Medicare	$13.21
Rate for Payer: MDX Hawaii PPO	$30.52
Rate for Payer: Ohana Health Plan Medicaid	$13.21
Rate for Payer: Ohana Health Plan Medicare	$13.21
Rate for Payer: UnitedHealthcare Medicaid	$18.88
Rate for Payer: UnitedHealthcare Medicare	$13.21
Rate for Payer: University Health Alliance Commercial	$22.93

Ammonia DLS

Facility

$132.00

Service Code	HCPCS 82140
Hospital Charge Code	422821405
Hospital Revenue Code	301
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

Ammonia DLS

Facility

$132.00

Service Code	HCPCS 82140
Hospital Charge Code	422821405
Hospital Revenue Code	301
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$55.44
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$121.44
Rate for Payer: Devoted Health Medicare	$55.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.14
Rate for Payer: Hawaii Medical Service Association Commercial	$18.21
Rate for Payer: Hawaii Medical Service Association Medicare	$55.44
Rate for Payer: Hawaii Western Management Group Commercial	$14.57
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$55.44
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$55.44
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$55.44
Rate for Payer: Ohana Health Plan Medicare	$55.44
Rate for Payer: UnitedHealthcare Medicaid	$20.14
Rate for Payer: UnitedHealthcare Medicare	$55.44
Rate for Payer: University Health Alliance Commercial	$37.67

Ammonia Level

Facility

$126.00

Service Code	HCPCS 82140
Hospital Charge Code	422821400
Hospital Revenue Code	301
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$52.92
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$115.92
Rate for Payer: Devoted Health Medicare	$52.92
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.14
Rate for Payer: Hawaii Medical Service Association Commercial	$18.21
Rate for Payer: Hawaii Medical Service Association Medicare	$52.92
Rate for Payer: Hawaii Western Management Group Commercial	$14.57
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$52.92
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$52.92
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$52.92
Rate for Payer: Ohana Health Plan Medicare	$52.92
Rate for Payer: UnitedHealthcare Medicaid	$20.14
Rate for Payer: UnitedHealthcare Medicare	$52.92
Rate for Payer: University Health Alliance Commercial	$37.67

Ammonia Level

Facility

$126.00

Service Code	HCPCS 82140
Hospital Charge Code	422821400
Hospital Revenue Code	301
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

Ammonium Lactate 12% Lotion [KMC]

Facility

$3.00

Service Code	NDC 31063128605
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

Ammonium Lactate 12% Lotion [KMC]

Facility

$3.00

Service Code	NDC 31063128605
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

amoxapine 100 mg Tab [KMC]

Facility

$8.63

Service Code	NDC 00591571501
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$8.37
Rate for Payer: AlohaCare Medicaid	$4.32
Rate for Payer: AlohaCare Medicare	$3.62
Rate for Payer: Cash Price	$5.61
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.94
Rate for Payer: Devoted Health Medicare	$3.62
Rate for Payer: Hawaii Medical Service Association Medicare	$3.62
Rate for Payer: Hawaii Western Management Group Commercial	$8.20
Rate for Payer: Health Management Network Commercial	$7.34
Rate for Payer: Humana Medicare	$3.62
Rate for Payer: Kaiser Permanente Commercial	$7.77
Rate for Payer: Kaiser Permanente Medicaid	$4.40
Rate for Payer: Kaiser Permanente Medicare	$3.62
Rate for Payer: MDX Hawaii PPO	$8.37
Rate for Payer: Ohana Health Plan Medicaid	$3.62
Rate for Payer: Ohana Health Plan Medicare	$3.62
Rate for Payer: UnitedHealthcare Medicaid	$5.18
Rate for Payer: UnitedHealthcare Medicare	$3.62
Rate for Payer: University Health Alliance Commercial	$6.29

amoxapine 100 mg Tab [KMC]

Facility

$8.63

Service Code	NDC 00591571501
Hospital Revenue Code	250
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$8.37
Rate for Payer: Cash Price	$5.61
Rate for Payer: Health Management Network Commercial	$7.34
Rate for Payer: Kaiser Permanente Commercial	$7.77
Rate for Payer: MDX Hawaii PPO	$8.37

Amoxicillin 400 mg/5 mL REC Susp [KMC]

Facility

$0.39

Service Code	NDC 65862007175
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: MDX Hawaii PPO	$0.38

Amoxicillin 400 mg/5 mL REC Susp [KMC]

Facility

$0.39

Service Code	NDC 65862007175
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.38
Rate for Payer: AlohaCare Medicaid	$0.20
Rate for Payer: AlohaCare Medicare	$0.16
Rate for Payer: Cash Price	$0.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.36
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$0.37
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Humana Medicare	$0.16
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: Kaiser Permanente Medicaid	$0.20
Rate for Payer: Kaiser Permanente Medicare	$0.16
Rate for Payer: MDX Hawaii PPO	$0.38
Rate for Payer: Ohana Health Plan Medicaid	$0.16
Rate for Payer: Ohana Health Plan Medicare	$0.16
Rate for Payer: UnitedHealthcare Medicaid	$0.23
Rate for Payer: UnitedHealthcare Medicare	$0.16
Rate for Payer: University Health Alliance Commercial	$0.28

amoxicillin 500 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 00781261301
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

amoxicillin 500 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 00781261301
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

amoxicillin-clavulanate 500 mg-125 mg Tab [KMC]

Facility

$15.14

Service Code	NDC 16714029601
Hospital Revenue Code	250
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$14.69
Rate for Payer: Cash Price	$9.84
Rate for Payer: Health Management Network Commercial	$12.87
Rate for Payer: Kaiser Permanente Commercial	$13.63
Rate for Payer: MDX Hawaii PPO	$14.69

amoxicillin-clavulanate 500 mg-125 mg Tab [KMC]

Facility

$15.14

Service Code	NDC 16714029601
Hospital Revenue Code	250
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$14.69
Rate for Payer: AlohaCare Medicaid	$7.57
Rate for Payer: AlohaCare Medicare	$6.36
Rate for Payer: Cash Price	$9.84
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.93
Rate for Payer: Devoted Health Medicare	$6.36
Rate for Payer: Hawaii Medical Service Association Medicare	$6.36
Rate for Payer: Hawaii Western Management Group Commercial	$14.38
Rate for Payer: Health Management Network Commercial	$12.87
Rate for Payer: Humana Medicare	$6.36
Rate for Payer: Kaiser Permanente Commercial	$13.63
Rate for Payer: Kaiser Permanente Medicaid	$7.72
Rate for Payer: Kaiser Permanente Medicare	$6.36
Rate for Payer: MDX Hawaii PPO	$14.69
Rate for Payer: Ohana Health Plan Medicaid	$6.36
Rate for Payer: Ohana Health Plan Medicare	$6.36
Rate for Payer: UnitedHealthcare Medicaid	$9.08
Rate for Payer: UnitedHealthcare Medicare	$6.36
Rate for Payer: University Health Alliance Commercial	$11.04

amoxicillin-clavulanate 875-125 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 81964022114
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

amoxicillin-clavulanate 875-125 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 81964022114
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

amphetamine-dextroamphetamine 20 mg ER Cap [KMC]

Facility

$24.53

Service Code	NDC 31722018801
Hospital Revenue Code	250
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$23.79
Rate for Payer: AlohaCare Medicaid	$12.27
Rate for Payer: AlohaCare Medicare	$10.30
Rate for Payer: Cash Price	$15.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.57
Rate for Payer: Devoted Health Medicare	$10.30
Rate for Payer: Hawaii Medical Service Association Medicare	$10.30
Rate for Payer: Hawaii Western Management Group Commercial	$23.30
Rate for Payer: Health Management Network Commercial	$20.85
Rate for Payer: Humana Medicare	$10.30
Rate for Payer: Kaiser Permanente Commercial	$22.08
Rate for Payer: Kaiser Permanente Medicaid	$12.51
Rate for Payer: Kaiser Permanente Medicare	$10.30
Rate for Payer: MDX Hawaii PPO	$23.79
Rate for Payer: Ohana Health Plan Medicaid	$10.30
Rate for Payer: Ohana Health Plan Medicare	$10.30
Rate for Payer: UnitedHealthcare Medicaid	$14.72
Rate for Payer: UnitedHealthcare Medicare	$10.30
Rate for Payer: University Health Alliance Commercial	$17.88

amphetamine-dextroamphetamine 20 mg ER Cap [KMC]

Facility

$24.53

Service Code	NDC 31722018801
Hospital Revenue Code	250
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$23.79
Rate for Payer: Cash Price	$15.94
Rate for Payer: Health Management Network Commercial	$20.85
Rate for Payer: Kaiser Permanente Commercial	$22.08
Rate for Payer: MDX Hawaii PPO	$23.79

amphotericin B liposomal 50 mg REC vial [KMC]

Facility

$1,222.76

Service Code	HCPCS J0289
Hospital Revenue Code	636
Min. Negotiated Rate	$1,039.35
Max. Negotiated Rate	$1,186.08
Rate for Payer: Cash Price	$794.79
Rate for Payer: Health Management Network Commercial	$1,039.35
Rate for Payer: Kaiser Permanente Commercial	$1,100.48
Rate for Payer: MDX Hawaii PPO	$1,186.08

amphotericin B liposomal 50 mg REC vial [KMC]

Facility

$1,222.76

Service Code	HCPCS J0289
Hospital Revenue Code	636
Min. Negotiated Rate	$22.62
Max. Negotiated Rate	$1,186.08
Rate for Payer: AlohaCare Medicaid	$611.38
Rate for Payer: AlohaCare Medicare	$513.56
Rate for Payer: Cash Price	$794.79
Rate for Payer: Cash Price	$794.79
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,124.94
Rate for Payer: Devoted Health Medicare	$513.56
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$22.62
Rate for Payer: Hawaii Medical Service Association Commercial	$28.51
Rate for Payer: Hawaii Medical Service Association Medicare	$513.56
Rate for Payer: Hawaii Western Management Group Commercial	$1,161.62
Rate for Payer: Health Management Network Commercial	$1,039.35
Rate for Payer: Humana Medicare	$513.56
Rate for Payer: Kaiser Permanente Commercial	$1,100.48
Rate for Payer: Kaiser Permanente Medicaid	$623.61
Rate for Payer: Kaiser Permanente Medicare	$513.56
Rate for Payer: MDX Hawaii PPO	$1,186.08
Rate for Payer: Ohana Health Plan Medicaid	$513.56
Rate for Payer: Ohana Health Plan Medicare	$513.56
Rate for Payer: UnitedHealthcare Medicaid	$733.66
Rate for Payer: UnitedHealthcare Medicare	$513.56
Rate for Payer: University Health Alliance Commercial	$891.27

ampicillin 1 g Inj [KMC]

Facility

$28.80

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$27.94
Rate for Payer: AlohaCare Medicaid	$14.40
Rate for Payer: AlohaCare Medicare	$12.10
Rate for Payer: Cash Price	$18.72
Rate for Payer: Cash Price	$18.72
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$26.50
Rate for Payer: Devoted Health Medicare	$12.10
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Medicare	$12.10
Rate for Payer: Hawaii Western Management Group Commercial	$27.36
Rate for Payer: Health Management Network Commercial	$24.48
Rate for Payer: Humana Medicare	$12.10
Rate for Payer: Kaiser Permanente Commercial	$25.92
Rate for Payer: Kaiser Permanente Medicaid	$14.69
Rate for Payer: Kaiser Permanente Medicare	$12.10
Rate for Payer: MDX Hawaii PPO	$27.94
Rate for Payer: Ohana Health Plan Medicaid	$12.10
Rate for Payer: Ohana Health Plan Medicare	$12.10
Rate for Payer: UnitedHealthcare Medicaid	$17.28
Rate for Payer: UnitedHealthcare Medicare	$12.10
Rate for Payer: University Health Alliance Commercial	$20.99

ampicillin 1 g Inj [KMC]

Facility

$28.80

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$27.94
Rate for Payer: Cash Price	$18.72
Rate for Payer: Health Management Network Commercial	$24.48
Rate for Payer: Kaiser Permanente Commercial	$25.92
Rate for Payer: MDX Hawaii PPO	$27.94

Know your out-of-pocket cost for care.

All Charges