Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

SYRINGE 3CC

Facility

$51.00

Hospital Charge Code	8334
Hospital Revenue Code	270
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

SYRINGE 3CC

Facility

$51.00

Hospital Charge Code	8334
Hospital Revenue Code	270
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$21.42
Rate for Payer: Cash Price	$33.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.92
Rate for Payer: Devoted Health Medicare	$21.42
Rate for Payer: Hawaii Medical Service Association Medicare	$21.42
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$21.42
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$21.42
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$21.42
Rate for Payer: Ohana Health Plan Medicare	$21.42
Rate for Payer: UnitedHealthcare Medicare	$21.42
Rate for Payer: University Health Alliance Commercial	$37.17

SYRINGE 5CC

Facility

$2.00

Hospital Charge Code	8335
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

SYRINGE 5CC

Facility

$2.00

Hospital Charge Code	8335
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

SYRINGE CATH TIP 60CC

Facility

$2.00

Hospital Charge Code	8336
Hospital Revenue Code	272
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

SYRINGE CATH TIP 60CC

Facility

$2.00

Hospital Charge Code	8336
Hospital Revenue Code	272
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

SYRINGE LUER LOK 60CC

Facility

$4.00

Hospital Charge Code	8339
Hospital Revenue Code	272
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

SYRINGE LUER LOK 60CC

Facility

$4.00

Hospital Charge Code	8339
Hospital Revenue Code	272
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

T3, Free DLS

Facility

$309.00

Service Code	HCPCS 84481
Hospital Charge Code	422844815
Hospital Revenue Code	301
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$299.73
Rate for Payer: AlohaCare Medicaid	$154.50
Rate for Payer: AlohaCare Medicare	$129.78
Rate for Payer: Cash Price	$200.85
Rate for Payer: Cash Price	$200.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$284.28
Rate for Payer: Devoted Health Medicare	$129.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$23.41
Rate for Payer: Hawaii Medical Service Association Commercial	$21.18
Rate for Payer: Hawaii Medical Service Association Medicare	$129.78
Rate for Payer: Hawaii Western Management Group Commercial	$16.94
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Humana Medicare	$129.78
Rate for Payer: Kaiser Permanente Commercial	$278.10
Rate for Payer: Kaiser Permanente Medicaid	$157.59
Rate for Payer: Kaiser Permanente Medicare	$129.78
Rate for Payer: MDX Hawaii PPO	$299.73
Rate for Payer: Ohana Health Plan Medicaid	$129.78
Rate for Payer: Ohana Health Plan Medicare	$129.78
Rate for Payer: UnitedHealthcare Medicaid	$23.41
Rate for Payer: UnitedHealthcare Medicare	$129.78
Rate for Payer: University Health Alliance Commercial	$43.79

T3, Free DLS

Facility

$309.00

Service Code	HCPCS 84481
Hospital Charge Code	422844815
Hospital Revenue Code	301
Min. Negotiated Rate	$262.65
Max. Negotiated Rate	$299.73
Rate for Payer: Cash Price	$200.85
Rate for Payer: Health Management Network Commercial	$262.65
Rate for Payer: Kaiser Permanente Commercial	$278.10
Rate for Payer: MDX Hawaii PPO	$299.73

T3, Total DLS

Facility

$164.00

Service Code	HCPCS 84480
Hospital Charge Code	422844805
Hospital Revenue Code	301
Min. Negotiated Rate	$14.18
Max. Negotiated Rate	$159.08
Rate for Payer: AlohaCare Medicaid	$82.00
Rate for Payer: AlohaCare Medicare	$68.88
Rate for Payer: Cash Price	$106.60
Rate for Payer: Cash Price	$106.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$150.88
Rate for Payer: Devoted Health Medicare	$68.88
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.60
Rate for Payer: Hawaii Medical Service Association Commercial	$17.73
Rate for Payer: Hawaii Medical Service Association Medicare	$68.88
Rate for Payer: Hawaii Western Management Group Commercial	$14.18
Rate for Payer: Health Management Network Commercial	$139.40
Rate for Payer: Humana Medicare	$68.88
Rate for Payer: Kaiser Permanente Commercial	$147.60
Rate for Payer: Kaiser Permanente Medicaid	$83.64
Rate for Payer: Kaiser Permanente Medicare	$68.88
Rate for Payer: MDX Hawaii PPO	$159.08
Rate for Payer: Ohana Health Plan Medicaid	$68.88
Rate for Payer: Ohana Health Plan Medicare	$68.88
Rate for Payer: UnitedHealthcare Medicaid	$19.60
Rate for Payer: UnitedHealthcare Medicare	$68.88
Rate for Payer: University Health Alliance Commercial	$36.65

T3, Total DLS

Facility

$164.00

Service Code	HCPCS 84480
Hospital Charge Code	422844805
Hospital Revenue Code	301
Min. Negotiated Rate	$139.40
Max. Negotiated Rate	$159.08
Rate for Payer: Cash Price	$106.60
Rate for Payer: Health Management Network Commercial	$139.40
Rate for Payer: Kaiser Permanente Commercial	$147.60
Rate for Payer: MDX Hawaii PPO	$159.08

T4, Free DLS

Facility

$69.00

Service Code	HCPCS 84439
Hospital Charge Code	422844395
Hospital Revenue Code	301
Min. Negotiated Rate	$9.02
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	$12.46
Rate for Payer: Hawaii Medical Service Association Commercial	$11.28
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$9.02
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	$12.46
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$23.31

T4, Free DLS

Facility

$69.00

Service Code	HCPCS 84439
Hospital Charge Code	422844395
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

tacrolimus 0.1% topical Ointment [KMC]

Facility

$34.73

Service Code	NDC 68462053435
Hospital Revenue Code	250
Min. Negotiated Rate	$29.52
Max. Negotiated Rate	$33.69
Rate for Payer: Cash Price	$22.57
Rate for Payer: Health Management Network Commercial	$29.52
Rate for Payer: Kaiser Permanente Commercial	$31.26
Rate for Payer: MDX Hawaii PPO	$33.69

tacrolimus 0.1% topical Ointment [KMC]

Facility

$34.73

Service Code	NDC 68462053435
Hospital Revenue Code	250
Min. Negotiated Rate	$14.59
Max. Negotiated Rate	$33.69
Rate for Payer: AlohaCare Medicaid	$17.36
Rate for Payer: AlohaCare Medicare	$14.59
Rate for Payer: Cash Price	$22.57
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.95
Rate for Payer: Devoted Health Medicare	$14.59
Rate for Payer: Hawaii Medical Service Association Medicare	$14.59
Rate for Payer: Hawaii Western Management Group Commercial	$32.99
Rate for Payer: Health Management Network Commercial	$29.52
Rate for Payer: Humana Medicare	$14.59
Rate for Payer: Kaiser Permanente Commercial	$31.26
Rate for Payer: Kaiser Permanente Medicaid	$17.71
Rate for Payer: Kaiser Permanente Medicare	$14.59
Rate for Payer: MDX Hawaii PPO	$33.69
Rate for Payer: Ohana Health Plan Medicaid	$14.59
Rate for Payer: Ohana Health Plan Medicare	$14.59
Rate for Payer: UnitedHealthcare Medicaid	$20.84
Rate for Payer: UnitedHealthcare Medicare	$14.59
Rate for Payer: University Health Alliance Commercial	$25.31

tacrolimus 0.5 mg Cap [KMC]

Facility

$8.90

Service Code	HCPCS J7507
Hospital Revenue Code	636
Min. Negotiated Rate	$7.57
Max. Negotiated Rate	$8.63
Rate for Payer: Cash Price	$5.78
Rate for Payer: Health Management Network Commercial	$7.57
Rate for Payer: Kaiser Permanente Commercial	$8.01
Rate for Payer: MDX Hawaii PPO	$8.63

tacrolimus 0.5 mg Cap [KMC]

Facility

$8.90

Service Code	HCPCS J7507
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$8.63
Rate for Payer: AlohaCare Medicaid	$4.45
Rate for Payer: AlohaCare Medicare	$3.74
Rate for Payer: Cash Price	$5.78
Rate for Payer: Cash Price	$5.78
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.19
Rate for Payer: Devoted Health Medicare	$3.74
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Medicare	$3.74
Rate for Payer: Hawaii Western Management Group Commercial	$8.46
Rate for Payer: Health Management Network Commercial	$7.57
Rate for Payer: Humana Medicare	$3.74
Rate for Payer: Kaiser Permanente Commercial	$8.01
Rate for Payer: Kaiser Permanente Medicaid	$4.54
Rate for Payer: Kaiser Permanente Medicare	$3.74
Rate for Payer: MDX Hawaii PPO	$8.63
Rate for Payer: Ohana Health Plan Medicaid	$3.74
Rate for Payer: Ohana Health Plan Medicare	$3.74
Rate for Payer: UnitedHealthcare Medicaid	$5.34
Rate for Payer: UnitedHealthcare Medicare	$3.74
Rate for Payer: University Health Alliance Commercial	$6.49

tacrolimus 0.5 mg ER Cap [KMC]

Facility

$12.33

Service Code	HCPCS J7508
Hospital Revenue Code	636
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$11.96
Rate for Payer: Cash Price	$8.01
Rate for Payer: Health Management Network Commercial	$10.48
Rate for Payer: Kaiser Permanente Commercial	$11.10
Rate for Payer: MDX Hawaii PPO	$11.96

tacrolimus 0.5 mg ER Cap [KMC]

Facility

$12.33

Service Code	HCPCS J7508
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$11.96
Rate for Payer: AlohaCare Medicaid	$6.17
Rate for Payer: AlohaCare Medicare	$5.18
Rate for Payer: Cash Price	$8.01
Rate for Payer: Cash Price	$8.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.34
Rate for Payer: Devoted Health Medicare	$5.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.59
Rate for Payer: Hawaii Medical Service Association Medicare	$5.18
Rate for Payer: Hawaii Western Management Group Commercial	$11.71
Rate for Payer: Health Management Network Commercial	$10.48
Rate for Payer: Humana Medicare	$5.18
Rate for Payer: Kaiser Permanente Commercial	$11.10
Rate for Payer: Kaiser Permanente Medicaid	$6.29
Rate for Payer: Kaiser Permanente Medicare	$5.18
Rate for Payer: MDX Hawaii PPO	$11.96
Rate for Payer: Ohana Health Plan Medicaid	$5.18
Rate for Payer: Ohana Health Plan Medicare	$5.18
Rate for Payer: UnitedHealthcare Medicaid	$7.40
Rate for Payer: UnitedHealthcare Medicare	$5.18
Rate for Payer: University Health Alliance Commercial	$8.99

tacrolimus 1 mg Cap [KMC]

Facility

$17.82

Service Code	HCPCS J7507
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$17.29
Rate for Payer: AlohaCare Medicaid	$8.91
Rate for Payer: AlohaCare Medicare	$7.48
Rate for Payer: Cash Price	$11.58
Rate for Payer: Cash Price	$11.58
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.39
Rate for Payer: Devoted Health Medicare	$7.48
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.15
Rate for Payer: Hawaii Medical Service Association Medicare	$7.48
Rate for Payer: Hawaii Western Management Group Commercial	$16.93
Rate for Payer: Health Management Network Commercial	$15.15
Rate for Payer: Humana Medicare	$7.48
Rate for Payer: Kaiser Permanente Commercial	$16.04
Rate for Payer: Kaiser Permanente Medicaid	$9.09
Rate for Payer: Kaiser Permanente Medicare	$7.48
Rate for Payer: MDX Hawaii PPO	$17.29
Rate for Payer: Ohana Health Plan Medicaid	$7.48
Rate for Payer: Ohana Health Plan Medicare	$7.48
Rate for Payer: UnitedHealthcare Medicaid	$10.69
Rate for Payer: UnitedHealthcare Medicare	$7.48
Rate for Payer: University Health Alliance Commercial	$12.99

tacrolimus 1 mg Cap [KMC]

Facility

$17.82

Service Code	HCPCS J7507
Hospital Revenue Code	636
Min. Negotiated Rate	$15.15
Max. Negotiated Rate	$17.29
Rate for Payer: Cash Price	$11.58
Rate for Payer: Health Management Network Commercial	$15.15
Rate for Payer: Kaiser Permanente Commercial	$16.04
Rate for Payer: MDX Hawaii PPO	$17.29

tacrolimus 1 mg ER cap [KMC]

Facility

$24.66

Service Code	HCPCS J7508
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$23.92
Rate for Payer: AlohaCare Medicaid	$12.33
Rate for Payer: AlohaCare Medicare	$10.36
Rate for Payer: Cash Price	$16.03
Rate for Payer: Cash Price	$16.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.69
Rate for Payer: Devoted Health Medicare	$10.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.59
Rate for Payer: Hawaii Medical Service Association Medicare	$10.36
Rate for Payer: Hawaii Western Management Group Commercial	$23.43
Rate for Payer: Health Management Network Commercial	$20.96
Rate for Payer: Humana Medicare	$10.36
Rate for Payer: Kaiser Permanente Commercial	$22.19
Rate for Payer: Kaiser Permanente Medicaid	$12.58
Rate for Payer: Kaiser Permanente Medicare	$10.36
Rate for Payer: MDX Hawaii PPO	$23.92
Rate for Payer: Ohana Health Plan Medicaid	$10.36
Rate for Payer: Ohana Health Plan Medicare	$10.36
Rate for Payer: UnitedHealthcare Medicaid	$14.80
Rate for Payer: UnitedHealthcare Medicare	$10.36
Rate for Payer: University Health Alliance Commercial	$17.97

tacrolimus 1 mg ER cap [KMC]

Facility

$24.66

Service Code	HCPCS J7508
Hospital Revenue Code	636
Min. Negotiated Rate	$20.96
Max. Negotiated Rate	$23.92
Rate for Payer: Cash Price	$16.03
Rate for Payer: Health Management Network Commercial	$20.96
Rate for Payer: Kaiser Permanente Commercial	$22.19
Rate for Payer: MDX Hawaii PPO	$23.92

tacrolimus 5 mg ER cap [KMC]

Facility

$113.03

Service Code	HCPCS J7508
Hospital Revenue Code	636
Min. Negotiated Rate	$96.08
Max. Negotiated Rate	$109.64
Rate for Payer: Cash Price	$73.47
Rate for Payer: Health Management Network Commercial	$96.08
Rate for Payer: Kaiser Permanente Commercial	$101.73
Rate for Payer: MDX Hawaii PPO	$109.64

Know your out-of-pocket cost for care.

All Charges