Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

sodium chloride bacteriostatic 0.9% Sol[KMC]

Facility

$0.18

Service Code	NDC 00409196607
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.17
Rate for Payer: AlohaCare Medicaid	$0.09
Rate for Payer: AlohaCare Medicare	$0.08
Rate for Payer: Cash Price	$0.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.17
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Hawaii Medical Service Association Medicare	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$0.17
Rate for Payer: Health Management Network Commercial	$0.15
Rate for Payer: Humana Medicare	$0.08
Rate for Payer: Kaiser Permanente Commercial	$0.16
Rate for Payer: Kaiser Permanente Medicaid	$0.09
Rate for Payer: Kaiser Permanente Medicare	$0.08
Rate for Payer: MDX Hawaii PPO	$0.17
Rate for Payer: Ohana Health Plan Medicaid	$0.08
Rate for Payer: Ohana Health Plan Medicare	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.08
Rate for Payer: University Health Alliance Commercial	$0.13

sodium chloride bacteriostatic 0.9% Sol[KMC]

Facility

$0.18

Service Code	NDC 00409196607
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Management Network Commercial	$0.15
Rate for Payer: Kaiser Permanente Commercial	$0.16
Rate for Payer: MDX Hawaii PPO	$0.17

sodium chloride nasal 0.65% Spray [KMC]

Facility

$0.33

Service Code	NDC 62011008601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.32
Rate for Payer: AlohaCare Medicaid	$0.17
Rate for Payer: AlohaCare Medicare	$0.14
Rate for Payer: Cash Price	$0.21
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.30
Rate for Payer: Devoted Health Medicare	$0.14
Rate for Payer: Hawaii Medical Service Association Medicare	$0.14
Rate for Payer: Hawaii Western Management Group Commercial	$0.31
Rate for Payer: Health Management Network Commercial	$0.28
Rate for Payer: Humana Medicare	$0.14
Rate for Payer: Kaiser Permanente Commercial	$0.30
Rate for Payer: Kaiser Permanente Medicaid	$0.17
Rate for Payer: Kaiser Permanente Medicare	$0.14
Rate for Payer: MDX Hawaii PPO	$0.32
Rate for Payer: Ohana Health Plan Medicaid	$0.14
Rate for Payer: Ohana Health Plan Medicare	$0.14
Rate for Payer: UnitedHealthcare Medicaid	$0.20
Rate for Payer: UnitedHealthcare Medicare	$0.14
Rate for Payer: University Health Alliance Commercial	$0.24

sodium chloride nasal 0.65% Spray [KMC]

Facility

$0.33

Service Code	NDC 62011008601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Management Network Commercial	$0.28
Rate for Payer: Kaiser Permanente Commercial	$0.30
Rate for Payer: MDX Hawaii PPO	$0.32

Sodium DLS

Facility

$69.00

Service Code	HCPCS 84295
Hospital Charge Code	422842955
Hospital Revenue Code	301
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.65
Rate for Payer: Hawaii Medical Service Association Commercial	$6.01
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$4.81
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$6.65
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$12.43

Sodium DLS

Facility

$69.00

Service Code	HCPCS 84295
Hospital Charge Code	422842955
Hospital Revenue Code	301
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

sodium ferric gluconate 62.5 mg / 5 mL Soln [KMC]

Facility

$8.51

Service Code	HCPCS J2916
Hospital Revenue Code	636
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$8.25
Rate for Payer: AlohaCare Medicaid	$4.25
Rate for Payer: AlohaCare Medicare	$3.57
Rate for Payer: Cash Price	$5.53
Rate for Payer: Cash Price	$5.53
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.83
Rate for Payer: Devoted Health Medicare	$3.57
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.18
Rate for Payer: Hawaii Medical Service Association Medicare	$3.57
Rate for Payer: Hawaii Western Management Group Commercial	$8.08
Rate for Payer: Health Management Network Commercial	$7.23
Rate for Payer: Humana Medicare	$3.57
Rate for Payer: Kaiser Permanente Commercial	$7.66
Rate for Payer: Kaiser Permanente Medicaid	$4.34
Rate for Payer: Kaiser Permanente Medicare	$3.57
Rate for Payer: MDX Hawaii PPO	$8.25
Rate for Payer: Ohana Health Plan Medicaid	$3.57
Rate for Payer: Ohana Health Plan Medicare	$3.57
Rate for Payer: UnitedHealthcare Medicaid	$5.11
Rate for Payer: UnitedHealthcare Medicare	$3.57
Rate for Payer: University Health Alliance Commercial	$6.20

sodium ferric gluconate 62.5 mg / 5 mL Soln [KMC]

Facility

$8.51

Service Code	HCPCS J2916
Hospital Revenue Code	636
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$8.25
Rate for Payer: Cash Price	$5.53
Rate for Payer: Health Management Network Commercial	$7.23
Rate for Payer: Kaiser Permanente Commercial	$7.66
Rate for Payer: MDX Hawaii PPO	$8.25

sodium hypochlorite 0.125% (Qtr Str) Top Soln [KMC]

Facility

$0.12

Service Code	NDC 00436067216
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.12
Rate for Payer: AlohaCare Medicaid	$0.06
Rate for Payer: AlohaCare Medicare	$0.05
Rate for Payer: Cash Price	$0.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.11
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Hawaii Medical Service Association Medicare	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$0.11
Rate for Payer: Health Management Network Commercial	$0.10
Rate for Payer: Humana Medicare	$0.05
Rate for Payer: Kaiser Permanente Commercial	$0.11
Rate for Payer: Kaiser Permanente Medicaid	$0.06
Rate for Payer: Kaiser Permanente Medicare	$0.05
Rate for Payer: MDX Hawaii PPO	$0.12
Rate for Payer: Ohana Health Plan Medicaid	$0.05
Rate for Payer: Ohana Health Plan Medicare	$0.05
Rate for Payer: UnitedHealthcare Medicaid	$0.07
Rate for Payer: UnitedHealthcare Medicare	$0.05
Rate for Payer: University Health Alliance Commercial	$0.09

sodium hypochlorite 0.125% (Qtr Str) Top Soln [KMC]

Facility

$0.12

Service Code	NDC 00436067216
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Management Network Commercial	$0.10
Rate for Payer: Kaiser Permanente Commercial	$0.11
Rate for Payer: MDX Hawaii PPO	$0.12

sodium hypochlorite 0.25% (Half Str) Top Soln [KMC]

Facility

$0.10

Service Code	NDC 00436093616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: AlohaCare Medicaid	$0.05
Rate for Payer: AlohaCare Medicare	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$0.10
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.10
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.06
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

sodium hypochlorite 0.25% (Half Str) Top Soln [KMC]

Facility

$0.10

Service Code	NDC 00436093616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: MDX Hawaii PPO	$0.10

sodium hypochlorite 0.5% (Full Str) Top Soln [KMC]

Facility

$0.10

Service Code	NDC 00436094616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: AlohaCare Medicaid	$0.05
Rate for Payer: AlohaCare Medicare	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$0.10
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.10
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.06
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

sodium hypochlorite 0.5% (Full Str) Top Soln [KMC]

Facility

$0.10

Service Code	NDC 00436094616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: MDX Hawaii PPO	$0.10

Sodium Level

Facility

$69.00

Service Code	HCPCS 84295
Hospital Charge Code	422842950
Hospital Revenue Code	301
Min. Negotiated Rate	$4.81
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.65
Rate for Payer: Hawaii Medical Service Association Commercial	$6.01
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$4.81
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$6.65
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$12.43

Sodium Level

Facility

$69.00

Service Code	HCPCS 84295
Hospital Charge Code	422842950
Hospital Revenue Code	301
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

sodium nitrite-sodium thiosulfate 30 mg-250 mg/mL Sol [KMC]

Facility

$13.60

Service Code	NDC 60267081200
Hospital Revenue Code	250
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$13.19
Rate for Payer: Cash Price	$8.84
Rate for Payer: Health Management Network Commercial	$11.56
Rate for Payer: Kaiser Permanente Commercial	$12.24
Rate for Payer: MDX Hawaii PPO	$13.19

sodium nitrite-sodium thiosulfate 30 mg-250 mg/mL Sol [KMC]

Facility

$13.60

Service Code	NDC 60267081200
Hospital Revenue Code	250
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$13.19
Rate for Payer: AlohaCare Medicaid	$6.80
Rate for Payer: AlohaCare Medicare	$5.71
Rate for Payer: Cash Price	$8.84
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.51
Rate for Payer: Devoted Health Medicare	$5.71
Rate for Payer: Hawaii Medical Service Association Medicare	$5.71
Rate for Payer: Hawaii Western Management Group Commercial	$12.92
Rate for Payer: Health Management Network Commercial	$11.56
Rate for Payer: Humana Medicare	$5.71
Rate for Payer: Kaiser Permanente Commercial	$12.24
Rate for Payer: Kaiser Permanente Medicaid	$6.94
Rate for Payer: Kaiser Permanente Medicare	$5.71
Rate for Payer: MDX Hawaii PPO	$13.19
Rate for Payer: Ohana Health Plan Medicaid	$5.71
Rate for Payer: Ohana Health Plan Medicare	$5.71
Rate for Payer: UnitedHealthcare Medicaid	$8.16
Rate for Payer: UnitedHealthcare Medicare	$5.71
Rate for Payer: University Health Alliance Commercial	$9.91

sodium polystyrene sulfonate 15 g/60 mL Oral Susp [KMC]

Facility

$1.68

Service Code	NDC 46287000660
Hospital Revenue Code	250
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$1.63
Rate for Payer: Cash Price	$1.09
Rate for Payer: Health Management Network Commercial	$1.43
Rate for Payer: Kaiser Permanente Commercial	$1.51
Rate for Payer: MDX Hawaii PPO	$1.63

sodium polystyrene sulfonate 15 g/60 mL Oral Susp [KMC]

Facility

$1.68

Service Code	NDC 46287000660
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.63
Rate for Payer: AlohaCare Medicaid	$0.84
Rate for Payer: AlohaCare Medicare	$0.71
Rate for Payer: Cash Price	$1.09
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.55
Rate for Payer: Devoted Health Medicare	$0.71
Rate for Payer: Hawaii Medical Service Association Medicare	$0.71
Rate for Payer: Hawaii Western Management Group Commercial	$1.60
Rate for Payer: Health Management Network Commercial	$1.43
Rate for Payer: Humana Medicare	$0.71
Rate for Payer: Kaiser Permanente Commercial	$1.51
Rate for Payer: Kaiser Permanente Medicaid	$0.86
Rate for Payer: Kaiser Permanente Medicare	$0.71
Rate for Payer: MDX Hawaii PPO	$1.63
Rate for Payer: Ohana Health Plan Medicaid	$0.71
Rate for Payer: Ohana Health Plan Medicare	$0.71
Rate for Payer: UnitedHealthcare Medicaid	$1.01
Rate for Payer: UnitedHealthcare Medicare	$0.71
Rate for Payer: University Health Alliance Commercial	$1.22

Sodium, Urine DLS

Facility

$115.00

Service Code	HCPCS 84300
Hospital Charge Code	422843005
Hospital Revenue Code	301
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$111.55
Rate for Payer: AlohaCare Medicaid	$57.50
Rate for Payer: AlohaCare Medicare	$48.30
Rate for Payer: Cash Price	$74.75
Rate for Payer: Cash Price	$74.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$105.80
Rate for Payer: Devoted Health Medicare	$48.30
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.72
Rate for Payer: Hawaii Medical Service Association Commercial	$6.33
Rate for Payer: Hawaii Medical Service Association Medicare	$48.30
Rate for Payer: Hawaii Western Management Group Commercial	$5.06
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Humana Medicare	$48.30
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: Kaiser Permanente Medicare	$48.30
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: Ohana Health Plan Medicaid	$48.30
Rate for Payer: Ohana Health Plan Medicare	$48.30
Rate for Payer: UnitedHealthcare Medicaid	$6.72
Rate for Payer: UnitedHealthcare Medicare	$48.30
Rate for Payer: University Health Alliance Commercial	$12.56

Sodium, Urine DLS

Facility

$115.00

Service Code	HCPCS 84300
Hospital Charge Code	422843005
Hospital Revenue Code	301
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$74.75
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$103.50
Rate for Payer: MDX Hawaii PPO	$111.55

sodium zirconium cyclosilicate 10 gm packet [KMC]

Facility

$122.57

Service Code	NDC 00310111039
Hospital Revenue Code	250
Min. Negotiated Rate	$51.48
Max. Negotiated Rate	$118.89
Rate for Payer: AlohaCare Medicaid	$61.28
Rate for Payer: AlohaCare Medicare	$51.48
Rate for Payer: Cash Price	$79.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$112.76
Rate for Payer: Devoted Health Medicare	$51.48
Rate for Payer: Hawaii Medical Service Association Medicare	$51.48
Rate for Payer: Hawaii Western Management Group Commercial	$116.44
Rate for Payer: Health Management Network Commercial	$104.18
Rate for Payer: Humana Medicare	$51.48
Rate for Payer: Kaiser Permanente Commercial	$110.31
Rate for Payer: Kaiser Permanente Medicaid	$62.51
Rate for Payer: Kaiser Permanente Medicare	$51.48
Rate for Payer: MDX Hawaii PPO	$118.89
Rate for Payer: Ohana Health Plan Medicaid	$51.48
Rate for Payer: Ohana Health Plan Medicare	$51.48
Rate for Payer: UnitedHealthcare Medicaid	$73.54
Rate for Payer: UnitedHealthcare Medicare	$51.48
Rate for Payer: University Health Alliance Commercial	$89.34

sodium zirconium cyclosilicate 10 gm packet [KMC]

Facility

$122.57

Service Code	NDC 00310111039
Hospital Revenue Code	250
Min. Negotiated Rate	$104.18
Max. Negotiated Rate	$118.89
Rate for Payer: Cash Price	$79.67
Rate for Payer: Health Management Network Commercial	$104.18
Rate for Payer: Kaiser Permanente Commercial	$110.31
Rate for Payer: MDX Hawaii PPO	$118.89

sodium zirconium cyclosilicate 5 gm packet [KMC]

Facility

$113.34

Service Code	NDC 00310110539
Hospital Revenue Code	250
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$109.94
Rate for Payer: AlohaCare Medicaid	$56.67
Rate for Payer: AlohaCare Medicare	$47.60
Rate for Payer: Cash Price	$73.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$104.27
Rate for Payer: Devoted Health Medicare	$47.60
Rate for Payer: Hawaii Medical Service Association Medicare	$47.60
Rate for Payer: Hawaii Western Management Group Commercial	$107.67
Rate for Payer: Health Management Network Commercial	$96.34
Rate for Payer: Humana Medicare	$47.60
Rate for Payer: Kaiser Permanente Commercial	$102.01
Rate for Payer: Kaiser Permanente Medicaid	$57.80
Rate for Payer: Kaiser Permanente Medicare	$47.60
Rate for Payer: MDX Hawaii PPO	$109.94
Rate for Payer: Ohana Health Plan Medicaid	$47.60
Rate for Payer: Ohana Health Plan Medicare	$47.60
Rate for Payer: UnitedHealthcare Medicaid	$68.00
Rate for Payer: UnitedHealthcare Medicare	$47.60
Rate for Payer: University Health Alliance Commercial	$82.61

Know your out-of-pocket cost for care.

All Charges