Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

NONTRAUMATIC STUPOR AND COMA WITH MCC

Facility

$32,566.55

Service Code	MSDRG 080
Min. Negotiated Rate	$32,566.55
Max. Negotiated Rate	$32,566.55
Rate for Payer: Hawaii Medical Service Association Commercial	$32,566.55

NONTRAUMATIC STUPOR AND COMA WITHOUT MCC

Facility

$32,566.55

Service Code	MSDRG 081
Min. Negotiated Rate	$32,566.55
Max. Negotiated Rate	$32,566.55
Rate for Payer: Hawaii Medical Service Association Commercial	$32,566.55

norEPINEPHrine 4 mg / 4 mL IV Sol [KMC]

Facility

$24.52

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$20.84
Max. Negotiated Rate	$23.78
Rate for Payer: Cash Price	$15.94
Rate for Payer: Health Management Network Commercial	$20.84
Rate for Payer: Kaiser Permanente Commercial	$22.07
Rate for Payer: MDX Hawaii PPO	$23.78

norEPINEPHrine 4 mg / 4 mL IV Sol [KMC]

Facility

$24.52

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$23.78
Rate for Payer: AlohaCare Medicaid	$12.26
Rate for Payer: AlohaCare Medicare	$10.30
Rate for Payer: Cash Price	$15.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.56
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	$23.29
Rate for Payer: Health Management Network Commercial	$20.84
Rate for Payer: Humana Medicare	$10.30
Rate for Payer: Kaiser Permanente Commercial	$22.07
Rate for Payer: Kaiser Permanente Medicaid	$12.51
Rate for Payer: Kaiser Permanente Medicare	$10.30
Rate for Payer: MDX Hawaii PPO	$23.78
Rate for Payer: Ohana Health Plan Medicaid	$10.30
Rate for Payer: Ohana Health Plan Medicare	$10.30
Rate for Payer: UnitedHealthcare Medicaid	$14.71
Rate for Payer: UnitedHealthcare Medicare	$10.30
Rate for Payer: University Health Alliance Commercial	$17.87

NORMAL NEWBORN

Facility

$2,678.33

Service Code	MSDRG 795
Min. Negotiated Rate	$2,678.33
Max. Negotiated Rate	$2,678.33
Rate for Payer: Hawaii Medical Service Association Commercial	$2,678.33

nortriptyline 10 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 75907006901
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

nortriptyline 10 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 75907006901
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

nortriptyline 25 mg Cap [KMC]

Facility

$5.87

Service Code	NDC 00093081101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.99
Max. Negotiated Rate	$5.69
Rate for Payer: Cash Price	$3.82
Rate for Payer: Health Management Network Commercial	$4.99
Rate for Payer: Kaiser Permanente Commercial	$5.28
Rate for Payer: MDX Hawaii PPO	$5.69

nortriptyline 25 mg Cap [KMC]

Facility

$5.87

Service Code	NDC 00093081101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$5.69
Rate for Payer: AlohaCare Medicaid	$2.94
Rate for Payer: AlohaCare Medicare	$2.47
Rate for Payer: Cash Price	$3.82
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.40
Rate for Payer: Devoted Health Medicare	$2.47
Rate for Payer: Hawaii Medical Service Association Medicare	$2.47
Rate for Payer: Hawaii Western Management Group Commercial	$5.58
Rate for Payer: Health Management Network Commercial	$4.99
Rate for Payer: Humana Medicare	$2.47
Rate for Payer: Kaiser Permanente Commercial	$5.28
Rate for Payer: Kaiser Permanente Medicaid	$2.99
Rate for Payer: Kaiser Permanente Medicare	$2.47
Rate for Payer: MDX Hawaii PPO	$5.69
Rate for Payer: Ohana Health Plan Medicaid	$2.47
Rate for Payer: Ohana Health Plan Medicare	$2.47
Rate for Payer: UnitedHealthcare Medicaid	$3.52
Rate for Payer: UnitedHealthcare Medicare	$2.47
Rate for Payer: University Health Alliance Commercial	$4.28

nortriptyline 50 mg Cap [KMC]

Facility

$11.06

Service Code	NDC 00093081201
Hospital Revenue Code	250
Min. Negotiated Rate	$9.40
Max. Negotiated Rate	$10.73
Rate for Payer: Cash Price	$7.19
Rate for Payer: Health Management Network Commercial	$9.40
Rate for Payer: Kaiser Permanente Commercial	$9.95
Rate for Payer: MDX Hawaii PPO	$10.73

nortriptyline 50 mg Cap [KMC]

Facility

$11.06

Service Code	NDC 00093081201
Hospital Revenue Code	250
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$10.73
Rate for Payer: AlohaCare Medicaid	$5.53
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$7.19
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.18
Rate for Payer: Devoted Health Medicare	$4.65
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$10.51
Rate for Payer: Health Management Network Commercial	$9.40
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$9.95
Rate for Payer: Kaiser Permanente Medicaid	$5.64
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$10.73
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicaid	$6.64
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$8.06

nortriptyline 75 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 51672400405
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

nortriptyline 75 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 51672400405
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

NO SIGNIF DEP SYMP CAT BY STAND DEP ASSESS TOOL

Professional

Both

$0.01

Service Code	HCPCS 3352F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

NPWT 300CC CANISTER WITH GEL

Facility

$24.00

Hospital Charge Code	8814
Hospital Revenue Code	270
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$10.08
Rate for Payer: Cash Price	$15.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.08
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$10.08
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$10.08
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$10.08
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$10.08
Rate for Payer: Ohana Health Plan Medicare	$10.08
Rate for Payer: UnitedHealthcare Medicare	$10.08
Rate for Payer: University Health Alliance Commercial	$17.49

NPWT 300CC CANISTER WITH GEL

Facility

$24.00

Hospital Charge Code	8814
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

NPWT BLACK FOAM DRESSING KIT LARGE

Facility

$3.00

Hospital Charge Code	8813
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

NPWT BLACK FOAM DRESSING KIT LARGE

Facility

$3.00

Hospital Charge Code	8813
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

NPWT BLACK FOAM DRESSING KIT MEDIUM

Facility

$2.00

Hospital Charge Code	8812
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

NPWT BLACK FOAM DRESSING KIT MEDIUM

Facility

$2.00

Hospital Charge Code	8812
Hospital Revenue Code	270
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

NPWT BLACK FOAM DRESSING KIT SMALL

Facility

$24.00

Hospital Charge Code	8811
Hospital Revenue Code	270
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$10.08
Rate for Payer: Cash Price	$15.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.08
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$10.08
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$10.08
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$10.08
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$10.08
Rate for Payer: Ohana Health Plan Medicare	$10.08
Rate for Payer: UnitedHealthcare Medicare	$10.08
Rate for Payer: University Health Alliance Commercial	$17.49

NPWT BLACK FOAM DRESSING KIT SMALL

Facility

$24.00

Hospital Charge Code	8811
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

NPWT DRAPE

Facility

$2.00

Hospital Charge Code	8815
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

NPWT DRAPE

Facility

$2.00

Hospital Charge Code	8815
Hospital Revenue Code	270
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

NPWT WHITE FOAM DRESSING

Facility

$13.00

Hospital Charge Code	8810
Hospital Revenue Code	270
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$8.45
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

Know your out-of-pocket cost for care.

All Charges