Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

oxyCODONE 15 mg Tab [KMC]

Facility

$7.58

Service Code	NDC 00406851501
Hospital Revenue Code	250
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$7.35
Rate for Payer: Cash Price	$4.93
Rate for Payer: Health Management Network Commercial	$6.44
Rate for Payer: Kaiser Permanente Commercial	$6.82
Rate for Payer: MDX Hawaii PPO	$7.35

oxyCODONE 15 mg Tab [KMC]

Facility

$7.58

Service Code	NDC 00406851501
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$7.35
Rate for Payer: AlohaCare Medicaid	$3.79
Rate for Payer: AlohaCare Medicare	$3.18
Rate for Payer: Cash Price	$4.93
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.97
Rate for Payer: Devoted Health Medicare	$3.18
Rate for Payer: Hawaii Medical Service Association Medicare	$3.18
Rate for Payer: Hawaii Western Management Group Commercial	$7.20
Rate for Payer: Health Management Network Commercial	$6.44
Rate for Payer: Humana Medicare	$3.18
Rate for Payer: Kaiser Permanente Commercial	$6.82
Rate for Payer: Kaiser Permanente Medicaid	$3.87
Rate for Payer: Kaiser Permanente Medicare	$3.18
Rate for Payer: MDX Hawaii PPO	$7.35
Rate for Payer: Ohana Health Plan Medicaid	$3.18
Rate for Payer: Ohana Health Plan Medicare	$3.18
Rate for Payer: UnitedHealthcare Medicaid	$4.55
Rate for Payer: UnitedHealthcare Medicare	$3.18
Rate for Payer: University Health Alliance Commercial	$5.53

oxyCODONE 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00406055201
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

oxyCODONE 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00406055201
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

oxyCONTIN 10 mg ER Tab [KMC]

Facility

$23.48

Service Code	NDC 59011041010
Hospital Revenue Code	250
Min. Negotiated Rate	$19.96
Max. Negotiated Rate	$22.78
Rate for Payer: Cash Price	$15.26
Rate for Payer: Health Management Network Commercial	$19.96
Rate for Payer: Kaiser Permanente Commercial	$21.13
Rate for Payer: MDX Hawaii PPO	$22.78

oxyCONTIN 10 mg ER Tab [KMC]

Facility

$23.48

Service Code	NDC 59011041010
Hospital Revenue Code	250
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$22.78
Rate for Payer: AlohaCare Medicaid	$11.74
Rate for Payer: AlohaCare Medicare	$9.86
Rate for Payer: Cash Price	$15.26
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.60
Rate for Payer: Devoted Health Medicare	$9.86
Rate for Payer: Hawaii Medical Service Association Medicare	$9.86
Rate for Payer: Hawaii Western Management Group Commercial	$22.31
Rate for Payer: Health Management Network Commercial	$19.96
Rate for Payer: Humana Medicare	$9.86
Rate for Payer: Kaiser Permanente Commercial	$21.13
Rate for Payer: Kaiser Permanente Medicaid	$11.97
Rate for Payer: Kaiser Permanente Medicare	$9.86
Rate for Payer: MDX Hawaii PPO	$22.78
Rate for Payer: Ohana Health Plan Medicaid	$9.86
Rate for Payer: Ohana Health Plan Medicare	$9.86
Rate for Payer: UnitedHealthcare Medicaid	$14.09
Rate for Payer: UnitedHealthcare Medicare	$9.86
Rate for Payer: University Health Alliance Commercial	$17.11

OXYGEN 1 HOUR

Facility

$1,411.00

Hospital Charge Code	8399
Hospital Revenue Code	270
Min. Negotiated Rate	$1,199.35
Max. Negotiated Rate	$1,368.67
Rate for Payer: Cash Price	$917.15
Rate for Payer: Health Management Network Commercial	$1,199.35
Rate for Payer: Kaiser Permanente Commercial	$1,269.90
Rate for Payer: MDX Hawaii PPO	$1,368.67

OXYGEN 1 HOUR

Facility

$1,411.00

Hospital Charge Code	8399
Hospital Revenue Code	270
Min. Negotiated Rate	$592.62
Max. Negotiated Rate	$1,368.67
Rate for Payer: AlohaCare Medicaid	$705.50
Rate for Payer: AlohaCare Medicare	$592.62
Rate for Payer: Cash Price	$917.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,298.12
Rate for Payer: Devoted Health Medicare	$592.62
Rate for Payer: Hawaii Medical Service Association Medicare	$592.62
Rate for Payer: Hawaii Western Management Group Commercial	$1,340.45
Rate for Payer: Health Management Network Commercial	$1,199.35
Rate for Payer: Humana Medicare	$592.62
Rate for Payer: Kaiser Permanente Commercial	$1,269.90
Rate for Payer: Kaiser Permanente Medicaid	$719.61
Rate for Payer: Kaiser Permanente Medicare	$592.62
Rate for Payer: MDX Hawaii PPO	$1,368.67
Rate for Payer: Ohana Health Plan Medicaid	$592.62
Rate for Payer: Ohana Health Plan Medicare	$592.62
Rate for Payer: UnitedHealthcare Medicare	$592.62
Rate for Payer: University Health Alliance Commercial	$1,028.48

OXYGEN 24 HOUR

Facility

$6.00

Hospital Charge Code	8400
Hospital Revenue Code	270
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

OXYGEN 24 HOUR

Facility

$6.00

Hospital Charge Code	8400
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

OXYGEN FLOW MODULATOR SET

Facility

$208.00

Hospital Charge Code	8233
Hospital Revenue Code	270
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$135.20
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

OXYGEN FLOW MODULATOR SET

Facility

$208.00

Hospital Charge Code	8233
Hospital Revenue Code	270
Min. Negotiated Rate	$87.36
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$87.36
Rate for Payer: Cash Price	$135.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$191.36
Rate for Payer: Devoted Health Medicare	$87.36
Rate for Payer: Hawaii Medical Service Association Medicare	$87.36
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$87.36
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$87.36
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$87.36
Rate for Payer: Ohana Health Plan Medicare	$87.36
Rate for Payer: UnitedHealthcare Medicare	$87.36
Rate for Payer: University Health Alliance Commercial	$151.61

Oxymask

Facility

$4.00

Hospital Charge Code	10001
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

Oxymask

Facility

$4.00

Hospital Charge Code	10001
Hospital Revenue Code	270
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

oxymetazoline Nasal 0.05% Spry [KMC]

Facility

$0.55

Service Code	NDC 00904571135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.53
Rate for Payer: AlohaCare Medicaid	$0.28
Rate for Payer: AlohaCare Medicare	$0.23
Rate for Payer: Cash Price	$0.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.51
Rate for Payer: Devoted Health Medicare	$0.23
Rate for Payer: Hawaii Medical Service Association Medicare	$0.23
Rate for Payer: Hawaii Western Management Group Commercial	$0.52
Rate for Payer: Health Management Network Commercial	$0.47
Rate for Payer: Humana Medicare	$0.23
Rate for Payer: Kaiser Permanente Commercial	$0.50
Rate for Payer: Kaiser Permanente Medicaid	$0.28
Rate for Payer: Kaiser Permanente Medicare	$0.23
Rate for Payer: MDX Hawaii PPO	$0.53
Rate for Payer: Ohana Health Plan Medicaid	$0.23
Rate for Payer: Ohana Health Plan Medicare	$0.23
Rate for Payer: UnitedHealthcare Medicaid	$0.33
Rate for Payer: UnitedHealthcare Medicare	$0.23
Rate for Payer: University Health Alliance Commercial	$0.40

oxymetazoline Nasal 0.05% Spry [KMC]

Facility

$0.55

Service Code	NDC 00904571135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.53
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Management Network Commercial	$0.47
Rate for Payer: Kaiser Permanente Commercial	$0.50
Rate for Payer: MDX Hawaii PPO	$0.53

oxytocin 10 units/mL Inj Soln [KMC]

Facility

$7.20

Service Code	HCPCS J2590
Hospital Revenue Code	636
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$6.98
Rate for Payer: Cash Price	$4.68
Rate for Payer: Health Management Network Commercial	$6.12
Rate for Payer: Kaiser Permanente Commercial	$6.48
Rate for Payer: MDX Hawaii PPO	$6.98

oxytocin 10 units/mL Inj Soln [KMC]

Facility

$7.20

Service Code	HCPCS J2590
Hospital Revenue Code	636
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$6.98
Rate for Payer: AlohaCare Medicaid	$3.60
Rate for Payer: AlohaCare Medicare	$3.02
Rate for Payer: Cash Price	$4.68
Rate for Payer: Cash Price	$4.68
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.62
Rate for Payer: Devoted Health Medicare	$3.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.55
Rate for Payer: Hawaii Medical Service Association Medicare	$3.02
Rate for Payer: Hawaii Western Management Group Commercial	$6.84
Rate for Payer: Health Management Network Commercial	$6.12
Rate for Payer: Humana Medicare	$3.02
Rate for Payer: Kaiser Permanente Commercial	$6.48
Rate for Payer: Kaiser Permanente Medicaid	$3.67
Rate for Payer: Kaiser Permanente Medicare	$3.02
Rate for Payer: MDX Hawaii PPO	$6.98
Rate for Payer: Ohana Health Plan Medicaid	$3.02
Rate for Payer: Ohana Health Plan Medicare	$3.02
Rate for Payer: UnitedHealthcare Medicaid	$4.32
Rate for Payer: UnitedHealthcare Medicare	$3.02
Rate for Payer: University Health Alliance Commercial	$5.25

PAIN SEVERITY QUANTIFIED NO PAIN PRESENT

Professional

Both

$0.01

Service Code	HCPCS 1126F
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

PAIN SEVERITY QUANTIFIED PAIN PRESENT

Professional

Both

$0.01

Service Code	HCPCS 1125F
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	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
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

palbociclib 125 mg Cap [KMC]

Facility

$2,845.57

Service Code	NDC 00069018921
Hospital Revenue Code	250
Min. Negotiated Rate	$2,418.73
Max. Negotiated Rate	$2,760.20
Rate for Payer: Cash Price	$1,849.62
Rate for Payer: Health Management Network Commercial	$2,418.73
Rate for Payer: Kaiser Permanente Commercial	$2,561.01
Rate for Payer: MDX Hawaii PPO	$2,760.20

palbociclib 125 mg Cap [KMC]

Facility

$2,845.57

Service Code	NDC 00069018921
Hospital Revenue Code	250
Min. Negotiated Rate	$1,195.14
Max. Negotiated Rate	$2,760.20
Rate for Payer: AlohaCare Medicaid	$1,422.79
Rate for Payer: AlohaCare Medicare	$1,195.14
Rate for Payer: Cash Price	$1,849.62
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,617.92
Rate for Payer: Devoted Health Medicare	$1,195.14
Rate for Payer: Hawaii Medical Service Association Medicare	$1,195.14
Rate for Payer: Hawaii Western Management Group Commercial	$2,703.29
Rate for Payer: Health Management Network Commercial	$2,418.73
Rate for Payer: Humana Medicare	$1,195.14
Rate for Payer: Kaiser Permanente Commercial	$2,561.01
Rate for Payer: Kaiser Permanente Medicaid	$1,451.24
Rate for Payer: Kaiser Permanente Medicare	$1,195.14
Rate for Payer: MDX Hawaii PPO	$2,760.20
Rate for Payer: Ohana Health Plan Medicaid	$1,195.14
Rate for Payer: Ohana Health Plan Medicare	$1,195.14
Rate for Payer: UnitedHealthcare Medicaid	$1,707.34
Rate for Payer: UnitedHealthcare Medicare	$1,195.14
Rate for Payer: University Health Alliance Commercial	$2,074.14

paliperidone 117 mg/0.75 mL ER

Facility

$6,683.57

Service Code	HCPCS J2426
Hospital Revenue Code	636
Min. Negotiated Rate	$5,681.03
Max. Negotiated Rate	$6,483.06
Rate for Payer: Cash Price	$4,344.32
Rate for Payer: Health Management Network Commercial	$5,681.03
Rate for Payer: Kaiser Permanente Commercial	$6,015.21
Rate for Payer: MDX Hawaii PPO	$6,483.06

paliperidone 117 mg/0.75 mL ER

Facility

$6,683.57

Service Code	HCPCS J2426
Hospital Revenue Code	636
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$6,483.06
Rate for Payer: AlohaCare Medicaid	$3,341.78
Rate for Payer: AlohaCare Medicare	$2,807.10
Rate for Payer: Cash Price	$4,344.32
Rate for Payer: Cash Price	$4,344.32
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6,148.88
Rate for Payer: Devoted Health Medicare	$2,807.10
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$15.08
Rate for Payer: Hawaii Medical Service Association Commercial	$18.85
Rate for Payer: Hawaii Medical Service Association Medicare	$2,807.10
Rate for Payer: Hawaii Western Management Group Commercial	$6,349.39
Rate for Payer: Health Management Network Commercial	$5,681.03
Rate for Payer: Humana Medicare	$2,807.10
Rate for Payer: Kaiser Permanente Commercial	$6,015.21
Rate for Payer: Kaiser Permanente Medicaid	$3,408.62
Rate for Payer: Kaiser Permanente Medicare	$2,807.10
Rate for Payer: MDX Hawaii PPO	$6,483.06
Rate for Payer: Ohana Health Plan Medicaid	$2,807.10
Rate for Payer: Ohana Health Plan Medicare	$2,807.10
Rate for Payer: UnitedHealthcare Medicaid	$4,010.14
Rate for Payer: UnitedHealthcare Medicare	$2,807.10
Rate for Payer: University Health Alliance Commercial	$4,871.65

paliperidone 156 mg/mL ER [KMC]

Facility

$7,277.83

Service Code	HCPCS J2426
Hospital Revenue Code	636
Min. Negotiated Rate	$6,186.16
Max. Negotiated Rate	$7,059.50
Rate for Payer: Cash Price	$4,730.59
Rate for Payer: Health Management Network Commercial	$6,186.16
Rate for Payer: Kaiser Permanente Commercial	$6,550.05
Rate for Payer: MDX Hawaii PPO	$7,059.50

Know your out-of-pocket cost for care.

All Charges