Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

predniSONE 20 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J7512
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
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: 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 ABD/Non-ABD	$0.01
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

predniSONE 20 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J7512
Hospital Revenue Code	636
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

predniSONE 50 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J7512
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
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: 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 ABD/Non-ABD	$0.01
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

predniSONE 50 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J7512
Hospital Revenue Code	636
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

predniSONE 5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J7512
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
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: 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 ABD/Non-ABD	$0.01
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

predniSONE 5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J7512
Hospital Revenue Code	636
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

predniSONE 5 mg Tapering Dose Pack [KMC]

Facility

$3.22

Service Code	HCPCS J7512
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$3.12
Rate for Payer: AlohaCare Medicaid	$1.61
Rate for Payer: AlohaCare Medicare	$1.35
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cash Price	$2.09
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.96
Rate for Payer: Devoted Health Medicare	$1.35
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$1.35
Rate for Payer: Hawaii Western Management Group Commercial	$3.06
Rate for Payer: Health Management Network Commercial	$2.74
Rate for Payer: Humana Medicare	$1.35
Rate for Payer: Kaiser Permanente Commercial	$2.90
Rate for Payer: Kaiser Permanente Medicaid	$1.64
Rate for Payer: Kaiser Permanente Medicare	$1.35
Rate for Payer: MDX Hawaii PPO	$3.12
Rate for Payer: Ohana Health Plan Medicaid	$1.35
Rate for Payer: Ohana Health Plan Medicare	$1.35
Rate for Payer: UnitedHealthcare Medicaid	$1.93
Rate for Payer: UnitedHealthcare Medicare	$1.35
Rate for Payer: University Health Alliance Commercial	$2.35

predniSONE 5 mg Tapering Dose Pack [KMC]

Facility

$3.22

Service Code	HCPCS J7512
Hospital Revenue Code	636
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.12
Rate for Payer: Cash Price	$2.09
Rate for Payer: Health Management Network Commercial	$2.74
Rate for Payer: Kaiser Permanente Commercial	$2.90
Rate for Payer: MDX Hawaii PPO	$3.12

pregabalin 100 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001490
Hospital Revenue Code	250
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$32.70
Rate for Payer: Cash Price	$21.91
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: MDX Hawaii PPO	$32.70

pregabalin 100 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001490
Hospital Revenue Code	250
Min. Negotiated Rate	$14.16
Max. Negotiated Rate	$32.70
Rate for Payer: AlohaCare Medicaid	$16.86
Rate for Payer: AlohaCare Medicare	$14.16
Rate for Payer: Cash Price	$21.91
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.01
Rate for Payer: Devoted Health Medicare	$14.16
Rate for Payer: Hawaii Medical Service Association Medicare	$14.16
Rate for Payer: Hawaii Western Management Group Commercial	$32.02
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Humana Medicare	$14.16
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: Kaiser Permanente Medicaid	$17.19
Rate for Payer: Kaiser Permanente Medicare	$14.16
Rate for Payer: MDX Hawaii PPO	$32.70
Rate for Payer: Ohana Health Plan Medicaid	$14.16
Rate for Payer: Ohana Health Plan Medicare	$14.16
Rate for Payer: UnitedHealthcare Medicaid	$20.23
Rate for Payer: UnitedHealthcare Medicare	$14.16
Rate for Payer: University Health Alliance Commercial	$24.57

pregabalin 150 mg Cap [KMC]

Facility

$27.71

Service Code	NDC 00071101668
Hospital Revenue Code	250
Min. Negotiated Rate	$23.55
Max. Negotiated Rate	$26.88
Rate for Payer: Cash Price	$18.01
Rate for Payer: Health Management Network Commercial	$23.55
Rate for Payer: Kaiser Permanente Commercial	$24.94
Rate for Payer: MDX Hawaii PPO	$26.88

pregabalin 150 mg Cap [KMC]

Facility

$27.71

Service Code	NDC 00071101668
Hospital Revenue Code	250
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$26.88
Rate for Payer: AlohaCare Medicaid	$13.86
Rate for Payer: AlohaCare Medicare	$11.64
Rate for Payer: Cash Price	$18.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$25.49
Rate for Payer: Devoted Health Medicare	$11.64
Rate for Payer: Hawaii Medical Service Association Medicare	$11.64
Rate for Payer: Hawaii Western Management Group Commercial	$26.32
Rate for Payer: Health Management Network Commercial	$23.55
Rate for Payer: Humana Medicare	$11.64
Rate for Payer: Kaiser Permanente Commercial	$24.94
Rate for Payer: Kaiser Permanente Medicaid	$14.13
Rate for Payer: Kaiser Permanente Medicare	$11.64
Rate for Payer: MDX Hawaii PPO	$26.88
Rate for Payer: Ohana Health Plan Medicaid	$11.64
Rate for Payer: Ohana Health Plan Medicare	$11.64
Rate for Payer: UnitedHealthcare Medicaid	$16.63
Rate for Payer: UnitedHealthcare Medicare	$11.64
Rate for Payer: University Health Alliance Commercial	$20.20

pregabalin 200 mg Cap [KMC]

Facility

$27.71

Service Code	NDC 00071101768
Hospital Revenue Code	250
Min. Negotiated Rate	$23.55
Max. Negotiated Rate	$26.88
Rate for Payer: Cash Price	$18.01
Rate for Payer: Health Management Network Commercial	$23.55
Rate for Payer: Kaiser Permanente Commercial	$24.94
Rate for Payer: MDX Hawaii PPO	$26.88

pregabalin 200 mg Cap [KMC]

Facility

$27.71

Service Code	NDC 00071101768
Hospital Revenue Code	250
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$26.88
Rate for Payer: AlohaCare Medicaid	$13.86
Rate for Payer: AlohaCare Medicare	$11.64
Rate for Payer: Cash Price	$18.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$25.49
Rate for Payer: Devoted Health Medicare	$11.64
Rate for Payer: Hawaii Medical Service Association Medicare	$11.64
Rate for Payer: Hawaii Western Management Group Commercial	$26.32
Rate for Payer: Health Management Network Commercial	$23.55
Rate for Payer: Humana Medicare	$11.64
Rate for Payer: Kaiser Permanente Commercial	$24.94
Rate for Payer: Kaiser Permanente Medicaid	$14.13
Rate for Payer: Kaiser Permanente Medicare	$11.64
Rate for Payer: MDX Hawaii PPO	$26.88
Rate for Payer: Ohana Health Plan Medicaid	$11.64
Rate for Payer: Ohana Health Plan Medicare	$11.64
Rate for Payer: UnitedHealthcare Medicaid	$16.63
Rate for Payer: UnitedHealthcare Medicare	$11.64
Rate for Payer: University Health Alliance Commercial	$20.20

pregabalin 25 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001190
Hospital Revenue Code	250
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$32.70
Rate for Payer: Cash Price	$21.91
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: MDX Hawaii PPO	$32.70

pregabalin 25 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001190
Hospital Revenue Code	250
Min. Negotiated Rate	$14.16
Max. Negotiated Rate	$32.70
Rate for Payer: AlohaCare Medicaid	$16.86
Rate for Payer: AlohaCare Medicare	$14.16
Rate for Payer: Cash Price	$21.91
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.01
Rate for Payer: Devoted Health Medicare	$14.16
Rate for Payer: Hawaii Medical Service Association Medicare	$14.16
Rate for Payer: Hawaii Western Management Group Commercial	$32.02
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Humana Medicare	$14.16
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: Kaiser Permanente Medicaid	$17.19
Rate for Payer: Kaiser Permanente Medicare	$14.16
Rate for Payer: MDX Hawaii PPO	$32.70
Rate for Payer: Ohana Health Plan Medicaid	$14.16
Rate for Payer: Ohana Health Plan Medicare	$14.16
Rate for Payer: UnitedHealthcare Medicaid	$20.23
Rate for Payer: UnitedHealthcare Medicare	$14.16
Rate for Payer: University Health Alliance Commercial	$24.57

pregabalin 300 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001890
Hospital Revenue Code	250
Min. Negotiated Rate	$14.16
Max. Negotiated Rate	$32.70
Rate for Payer: AlohaCare Medicaid	$16.86
Rate for Payer: AlohaCare Medicare	$14.16
Rate for Payer: Cash Price	$21.91
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.01
Rate for Payer: Devoted Health Medicare	$14.16
Rate for Payer: Hawaii Medical Service Association Medicare	$14.16
Rate for Payer: Hawaii Western Management Group Commercial	$32.02
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Humana Medicare	$14.16
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: Kaiser Permanente Medicaid	$17.19
Rate for Payer: Kaiser Permanente Medicare	$14.16
Rate for Payer: MDX Hawaii PPO	$32.70
Rate for Payer: Ohana Health Plan Medicaid	$14.16
Rate for Payer: Ohana Health Plan Medicare	$14.16
Rate for Payer: UnitedHealthcare Medicaid	$20.23
Rate for Payer: UnitedHealthcare Medicare	$14.16
Rate for Payer: University Health Alliance Commercial	$24.57

pregabalin 300 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001890
Hospital Revenue Code	250
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$32.70
Rate for Payer: Cash Price	$21.91
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: MDX Hawaii PPO	$32.70

pregabalin 50 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001290
Hospital Revenue Code	250
Min. Negotiated Rate	$14.16
Max. Negotiated Rate	$32.70
Rate for Payer: AlohaCare Medicaid	$16.86
Rate for Payer: AlohaCare Medicare	$14.16
Rate for Payer: Cash Price	$21.91
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.01
Rate for Payer: Devoted Health Medicare	$14.16
Rate for Payer: Hawaii Medical Service Association Medicare	$14.16
Rate for Payer: Hawaii Western Management Group Commercial	$32.02
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Humana Medicare	$14.16
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: Kaiser Permanente Medicaid	$17.19
Rate for Payer: Kaiser Permanente Medicare	$14.16
Rate for Payer: MDX Hawaii PPO	$32.70
Rate for Payer: Ohana Health Plan Medicaid	$14.16
Rate for Payer: Ohana Health Plan Medicare	$14.16
Rate for Payer: UnitedHealthcare Medicaid	$20.23
Rate for Payer: UnitedHealthcare Medicare	$14.16
Rate for Payer: University Health Alliance Commercial	$24.57

pregabalin 50 mg Cap [KMC]

Facility

$33.71

Service Code	NDC 72205001290
Hospital Revenue Code	250
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$32.70
Rate for Payer: Cash Price	$21.91
Rate for Payer: Health Management Network Commercial	$28.65
Rate for Payer: Kaiser Permanente Commercial	$30.34
Rate for Payer: MDX Hawaii PPO	$32.70

pregabalin 75 mg Cap [KMC]

Facility

$23.41

Service Code	NDC 62332012190
Hospital Revenue Code	250
Min. Negotiated Rate	$9.83
Max. Negotiated Rate	$22.71
Rate for Payer: AlohaCare Medicaid	$11.71
Rate for Payer: AlohaCare Medicare	$9.83
Rate for Payer: Cash Price	$15.22
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.54
Rate for Payer: Devoted Health Medicare	$9.83
Rate for Payer: Hawaii Medical Service Association Medicare	$9.83
Rate for Payer: Hawaii Western Management Group Commercial	$22.24
Rate for Payer: Health Management Network Commercial	$19.90
Rate for Payer: Humana Medicare	$9.83
Rate for Payer: Kaiser Permanente Commercial	$21.07
Rate for Payer: Kaiser Permanente Medicaid	$11.94
Rate for Payer: Kaiser Permanente Medicare	$9.83
Rate for Payer: MDX Hawaii PPO	$22.71
Rate for Payer: Ohana Health Plan Medicaid	$9.83
Rate for Payer: Ohana Health Plan Medicare	$9.83
Rate for Payer: UnitedHealthcare Medicaid	$14.05
Rate for Payer: UnitedHealthcare Medicare	$9.83
Rate for Payer: University Health Alliance Commercial	$17.06

pregabalin 75 mg Cap [KMC]

Facility

$23.41

Service Code	NDC 62332012190
Hospital Revenue Code	250
Min. Negotiated Rate	$19.90
Max. Negotiated Rate	$22.71
Rate for Payer: Cash Price	$15.22
Rate for Payer: Health Management Network Commercial	$19.90
Rate for Payer: Kaiser Permanente Commercial	$21.07
Rate for Payer: MDX Hawaii PPO	$22.71

PREMATURITY WITH MAJOR PROBLEMS

Facility

$61,577.80

Service Code	MSDRG 791
Min. Negotiated Rate	$61,577.80
Max. Negotiated Rate	$61,577.80
Rate for Payer: Hawaii Medical Service Association Commercial	$61,577.80

PREMATURITY WITHOUT MAJOR PROBLEMS

Facility

$12,325.04

Service Code	MSDRG 792
Min. Negotiated Rate	$12,325.04
Max. Negotiated Rate	$12,325.04
Rate for Payer: Hawaii Medical Service Association Commercial	$12,325.04

Pre-Pack - azithromycin 200 mg/5 mL REC Susp [KMC]

Facility

$4.65

Service Code	HCPCS Q0144
Hospital Revenue Code	637
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$4.51
Rate for Payer: Cash Price	$3.02
Rate for Payer: Health Management Network Commercial	$3.95
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: MDX Hawaii PPO	$4.51

Know your out-of-pocket cost for care.

All Charges