Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

tacrolimus 5 mg ER cap [KMC]

Facility

$113.03

Service Code	HCPCS J7508
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$109.64
Rate for Payer: AlohaCare Medicaid	$56.52
Rate for Payer: AlohaCare Medicare	$47.47
Rate for Payer: Cash Price	$73.47
Rate for Payer: Cash Price	$73.47
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$103.99
Rate for Payer: Devoted Health Medicare	$47.47
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.59
Rate for Payer: Hawaii Medical Service Association Medicare	$47.47
Rate for Payer: Hawaii Western Management Group Commercial	$107.38
Rate for Payer: Health Management Network Commercial	$96.08
Rate for Payer: Humana Medicare	$47.47
Rate for Payer: Kaiser Permanente Commercial	$101.73
Rate for Payer: Kaiser Permanente Medicaid	$57.65
Rate for Payer: Kaiser Permanente Medicare	$47.47
Rate for Payer: MDX Hawaii PPO	$109.64
Rate for Payer: Ohana Health Plan Medicaid	$47.47
Rate for Payer: Ohana Health Plan Medicare	$47.47
Rate for Payer: UnitedHealthcare Medicaid	$67.82
Rate for Payer: UnitedHealthcare Medicare	$47.47
Rate for Payer: University Health Alliance Commercial	$82.39

Tacrolimus DLS

Facility

$403.00

Service Code	HCPCS 80197
Hospital Charge Code	422801975
Hospital Revenue Code	301
Min. Negotiated Rate	$13.73
Max. Negotiated Rate	$390.91
Rate for Payer: AlohaCare Medicaid	$201.50
Rate for Payer: AlohaCare Medicare	$169.26
Rate for Payer: Cash Price	$261.95
Rate for Payer: Cash Price	$261.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$370.76
Rate for Payer: Devoted Health Medicare	$169.26
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.97
Rate for Payer: Hawaii Medical Service Association Commercial	$17.16
Rate for Payer: Hawaii Medical Service Association Medicare	$169.26
Rate for Payer: Hawaii Western Management Group Commercial	$13.73
Rate for Payer: Health Management Network Commercial	$342.55
Rate for Payer: Humana Medicare	$169.26
Rate for Payer: Kaiser Permanente Commercial	$362.70
Rate for Payer: Kaiser Permanente Medicaid	$205.53
Rate for Payer: Kaiser Permanente Medicare	$169.26
Rate for Payer: MDX Hawaii PPO	$390.91
Rate for Payer: Ohana Health Plan Medicaid	$169.26
Rate for Payer: Ohana Health Plan Medicare	$169.26
Rate for Payer: UnitedHealthcare Medicaid	$18.97
Rate for Payer: UnitedHealthcare Medicare	$169.26
Rate for Payer: University Health Alliance Commercial	$35.46

Tacrolimus DLS

Facility

$403.00

Service Code	HCPCS 80197
Hospital Charge Code	422801975
Hospital Revenue Code	301
Min. Negotiated Rate	$342.55
Max. Negotiated Rate	$390.91
Rate for Payer: Cash Price	$261.95
Rate for Payer: Health Management Network Commercial	$342.55
Rate for Payer: Kaiser Permanente Commercial	$362.70
Rate for Payer: MDX Hawaii PPO	$390.91

tadalafil 5 mg Tab [KMC]

Facility

$53.17

Service Code	NDC 16714007501
Hospital Revenue Code	250
Min. Negotiated Rate	$45.19
Max. Negotiated Rate	$51.57
Rate for Payer: Cash Price	$34.56
Rate for Payer: Health Management Network Commercial	$45.19
Rate for Payer: Kaiser Permanente Commercial	$47.85
Rate for Payer: MDX Hawaii PPO	$51.57

tadalafil 5 mg Tab [KMC]

Facility

$53.17

Service Code	NDC 16714007501
Hospital Revenue Code	250
Min. Negotiated Rate	$22.33
Max. Negotiated Rate	$51.57
Rate for Payer: AlohaCare Medicaid	$26.59
Rate for Payer: AlohaCare Medicare	$22.33
Rate for Payer: Cash Price	$34.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$48.92
Rate for Payer: Devoted Health Medicare	$22.33
Rate for Payer: Hawaii Medical Service Association Medicare	$22.33
Rate for Payer: Hawaii Western Management Group Commercial	$50.51
Rate for Payer: Health Management Network Commercial	$45.19
Rate for Payer: Humana Medicare	$22.33
Rate for Payer: Kaiser Permanente Commercial	$47.85
Rate for Payer: Kaiser Permanente Medicaid	$27.12
Rate for Payer: Kaiser Permanente Medicare	$22.33
Rate for Payer: MDX Hawaii PPO	$51.57
Rate for Payer: Ohana Health Plan Medicaid	$22.33
Rate for Payer: Ohana Health Plan Medicare	$22.33
Rate for Payer: UnitedHealthcare Medicaid	$31.90
Rate for Payer: UnitedHealthcare Medicare	$22.33
Rate for Payer: University Health Alliance Commercial	$38.76

tafluprost 0.0015% eye drops [KMC]

Facility

$34.08

Service Code	NDC 17478060930
Hospital Revenue Code	250
Min. Negotiated Rate	$28.97
Max. Negotiated Rate	$33.06
Rate for Payer: Cash Price	$22.15
Rate for Payer: Health Management Network Commercial	$28.97
Rate for Payer: Kaiser Permanente Commercial	$30.67
Rate for Payer: MDX Hawaii PPO	$33.06

tafluprost 0.0015% eye drops [KMC]

Facility

$34.08

Service Code	NDC 17478060930
Hospital Revenue Code	250
Min. Negotiated Rate	$14.31
Max. Negotiated Rate	$33.06
Rate for Payer: AlohaCare Medicaid	$17.04
Rate for Payer: AlohaCare Medicare	$14.31
Rate for Payer: Cash Price	$22.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.35
Rate for Payer: Devoted Health Medicare	$14.31
Rate for Payer: Hawaii Medical Service Association Medicare	$14.31
Rate for Payer: Hawaii Western Management Group Commercial	$32.38
Rate for Payer: Health Management Network Commercial	$28.97
Rate for Payer: Humana Medicare	$14.31
Rate for Payer: Kaiser Permanente Commercial	$30.67
Rate for Payer: Kaiser Permanente Medicaid	$17.38
Rate for Payer: Kaiser Permanente Medicare	$14.31
Rate for Payer: MDX Hawaii PPO	$33.06
Rate for Payer: Ohana Health Plan Medicaid	$14.31
Rate for Payer: Ohana Health Plan Medicare	$14.31
Rate for Payer: UnitedHealthcare Medicaid	$20.45
Rate for Payer: UnitedHealthcare Medicare	$14.31
Rate for Payer: University Health Alliance Commercial	$24.84

tamoxifen 10 mg Tab [KMC]

Facility

$7.58

Service Code	NDC 00591247260
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

tamoxifen 10 mg Tab [KMC]

Facility

$7.58

Service Code	NDC 00591247260
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

tamsulosin 0.4 mg Oral Cap [KMC]

Facility

$16.85

Service Code	NDC 72603011501
Hospital Revenue Code	250
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$16.34
Rate for Payer: AlohaCare Medicaid	$8.43
Rate for Payer: AlohaCare Medicare	$7.08
Rate for Payer: Cash Price	$10.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.50
Rate for Payer: Devoted Health Medicare	$7.08
Rate for Payer: Hawaii Medical Service Association Medicare	$7.08
Rate for Payer: Hawaii Western Management Group Commercial	$16.01
Rate for Payer: Health Management Network Commercial	$14.32
Rate for Payer: Humana Medicare	$7.08
Rate for Payer: Kaiser Permanente Commercial	$15.16
Rate for Payer: Kaiser Permanente Medicaid	$8.59
Rate for Payer: Kaiser Permanente Medicare	$7.08
Rate for Payer: MDX Hawaii PPO	$16.34
Rate for Payer: Ohana Health Plan Medicaid	$7.08
Rate for Payer: Ohana Health Plan Medicare	$7.08
Rate for Payer: UnitedHealthcare Medicaid	$10.11
Rate for Payer: UnitedHealthcare Medicare	$7.08
Rate for Payer: University Health Alliance Commercial	$12.28

tamsulosin 0.4 mg Oral Cap [KMC]

Facility

$16.85

Service Code	NDC 72603011501
Hospital Revenue Code	250
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$16.34
Rate for Payer: Cash Price	$10.95
Rate for Payer: Health Management Network Commercial	$14.32
Rate for Payer: Kaiser Permanente Commercial	$15.16
Rate for Payer: MDX Hawaii PPO	$16.34

TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION

Professional

Both

$212.00

Service Code	HCPCS 11103
Hospital Revenue Code	361
Min. Negotiated Rate	$17.69
Max. Negotiated Rate	$180.20
Rate for Payer: AlohaCare Medicaid	$22.19
Rate for Payer: AlohaCare Medicare	$17.69
Rate for Payer: Cash Price	$137.80
Rate for Payer: Cash Price	$137.80
Rate for Payer: Devoted Health Medicare	$17.69
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$22.19
Rate for Payer: Hawaii Medical Service Association Commercial	$31.84
Rate for Payer: Hawaii Medical Service Association Medicare	$17.69
Rate for Payer: Hawaii Western Management Group Commercial	$59.54
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Kaiser Permanente Commercial	$21.23
Rate for Payer: Kaiser Permanente Medicaid	$21.23
Rate for Payer: Kaiser Permanente Medicare	$21.23
Rate for Payer: Ohana Health Plan Medicaid	$22.19
Rate for Payer: Ohana Health Plan Medicare	$17.69
Rate for Payer: UnitedHealthcare Medicaid	$22.19
Rate for Payer: UnitedHealthcare Medicare	$17.69
Rate for Payer: University Health Alliance Commercial	$25.44

TANGENTIAL BIOPSY SKIN SINGLE LESION

Professional

Both

$425.00

Service Code	HCPCS 11102
Hospital Revenue Code	361
Min. Negotiated Rate	$30.13
Max. Negotiated Rate	$361.25
Rate for Payer: AlohaCare Medicaid	$38.19
Rate for Payer: AlohaCare Medicare	$30.13
Rate for Payer: Cash Price	$276.25
Rate for Payer: Cash Price	$276.25
Rate for Payer: Devoted Health Medicare	$30.13
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$38.19
Rate for Payer: Hawaii Medical Service Association Commercial	$60.04
Rate for Payer: Hawaii Medical Service Association Medicare	$30.13
Rate for Payer: Hawaii Western Management Group Commercial	$110.50
Rate for Payer: Health Management Network Commercial	$361.25
Rate for Payer: Kaiser Permanente Commercial	$36.16
Rate for Payer: Kaiser Permanente Medicaid	$36.16
Rate for Payer: Kaiser Permanente Medicare	$36.16
Rate for Payer: Ohana Health Plan Medicaid	$38.19
Rate for Payer: Ohana Health Plan Medicare	$30.13
Rate for Payer: UnitedHealthcare Medicaid	$38.19
Rate for Payer: UnitedHealthcare Medicare	$30.13
Rate for Payer: University Health Alliance Commercial	$43.67

TB SYRINGE 1CC

Facility

$6.00

Hospital Charge Code	8340
Hospital Revenue Code	272
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

TB SYRINGE 1CC

Facility

$6.00

Hospital Charge Code	8340
Hospital Revenue Code	272
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

TDap BOOSTRIX Vaccine Susp [KMC]

Facility

$426.48

Service Code	NDC 58160084252
Hospital Revenue Code	250
Min. Negotiated Rate	$179.12
Max. Negotiated Rate	$413.69
Rate for Payer: AlohaCare Medicaid	$213.24
Rate for Payer: AlohaCare Medicare	$179.12
Rate for Payer: Cash Price	$277.21
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$392.36
Rate for Payer: Devoted Health Medicare	$179.12
Rate for Payer: Hawaii Medical Service Association Medicare	$179.12
Rate for Payer: Hawaii Western Management Group Commercial	$405.16
Rate for Payer: Health Management Network Commercial	$362.51
Rate for Payer: Humana Medicare	$179.12
Rate for Payer: Kaiser Permanente Commercial	$383.83
Rate for Payer: Kaiser Permanente Medicaid	$217.50
Rate for Payer: Kaiser Permanente Medicare	$179.12
Rate for Payer: MDX Hawaii PPO	$413.69
Rate for Payer: Ohana Health Plan Medicaid	$179.12
Rate for Payer: Ohana Health Plan Medicare	$179.12
Rate for Payer: UnitedHealthcare Medicaid	$255.89
Rate for Payer: UnitedHealthcare Medicare	$179.12
Rate for Payer: University Health Alliance Commercial	$310.86

TDap BOOSTRIX Vaccine Susp [KMC]

Facility

$426.48

Service Code	NDC 58160084252
Hospital Revenue Code	250
Min. Negotiated Rate	$362.51
Max. Negotiated Rate	$413.69
Rate for Payer: Cash Price	$277.21
Rate for Payer: Health Management Network Commercial	$362.51
Rate for Payer: Kaiser Permanente Commercial	$383.83
Rate for Payer: MDX Hawaii PPO	$413.69

TDAP VACCINE 7 YRS/> IM

Professional

Both

$103.00

Service Code	HCPCS 90715
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$87.55
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$39.48
Rate for Payer: Cash Price	$66.95
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$39.48
Rate for Payer: Hawaii Medical Service Association Medicare	$39.48
Rate for Payer: Hawaii Western Management Group Commercial	$46.89
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$47.38
Rate for Payer: Kaiser Permanente Medicaid	$47.38
Rate for Payer: Kaiser Permanente Medicare	$47.38
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$39.48
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$39.48

TDAP VACCINE 7 YRS/> IM

Professional

Both

$0.01

Service Code	HCPCS 90715 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$46.89
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$46.89
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE

Professional

Both

$0.01

Service Code	HCPCS 90714 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$20.25
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$20.25
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE

Professional

Both

$62.00

Service Code	HCPCS 90714
Hospital Revenue Code	636
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$52.70
Rate for Payer: AlohaCare Medicare	$38.75
Rate for Payer: Cash Price	$40.30
Rate for Payer: Cash Price	$40.30
Rate for Payer: Devoted Health Medicare	$38.75
Rate for Payer: Hawaii Medical Service Association Medicare	$38.75
Rate for Payer: Hawaii Western Management Group Commercial	$20.25
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$46.50
Rate for Payer: Kaiser Permanente Medicaid	$46.50
Rate for Payer: Kaiser Permanente Medicare	$46.50
Rate for Payer: Ohana Health Plan Medicare	$38.75
Rate for Payer: UnitedHealthcare Medicare	$38.75

telavancin 750 mg vial [KMC]

Facility

$2,395.92

Service Code	HCPCS J3095
Hospital Revenue Code	636
Min. Negotiated Rate	$2,036.53
Max. Negotiated Rate	$2,324.04
Rate for Payer: Cash Price	$1,557.35
Rate for Payer: Health Management Network Commercial	$2,036.53
Rate for Payer: Kaiser Permanente Commercial	$2,156.33
Rate for Payer: MDX Hawaii PPO	$2,324.04

telavancin 750 mg vial [KMC]

Facility

$2,395.92

Service Code	HCPCS J3095
Hospital Revenue Code	636
Min. Negotiated Rate	$7.47
Max. Negotiated Rate	$2,324.04
Rate for Payer: AlohaCare Medicaid	$1,197.96
Rate for Payer: AlohaCare Medicare	$1,006.29
Rate for Payer: Cash Price	$1,557.35
Rate for Payer: Cash Price	$1,557.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,204.25
Rate for Payer: Devoted Health Medicare	$1,006.29
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.47
Rate for Payer: Hawaii Medical Service Association Commercial	$8.79
Rate for Payer: Hawaii Medical Service Association Medicare	$1,006.29
Rate for Payer: Hawaii Western Management Group Commercial	$2,276.12
Rate for Payer: Health Management Network Commercial	$2,036.53
Rate for Payer: Humana Medicare	$1,006.29
Rate for Payer: Kaiser Permanente Commercial	$2,156.33
Rate for Payer: Kaiser Permanente Medicaid	$1,221.92
Rate for Payer: Kaiser Permanente Medicare	$1,006.29
Rate for Payer: MDX Hawaii PPO	$2,324.04
Rate for Payer: Ohana Health Plan Medicaid	$1,006.29
Rate for Payer: Ohana Health Plan Medicare	$1,006.29
Rate for Payer: UnitedHealthcare Medicaid	$1,437.55
Rate for Payer: UnitedHealthcare Medicare	$1,006.29
Rate for Payer: University Health Alliance Commercial	$1,746.39

TELFA 3X8 STERILE

Facility

$97.00

Hospital Charge Code	8341
Hospital Revenue Code	272
Min. Negotiated Rate	$40.74
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$40.74
Rate for Payer: Cash Price	$63.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$89.24
Rate for Payer: Devoted Health Medicare	$40.74
Rate for Payer: Hawaii Medical Service Association Medicare	$40.74
Rate for Payer: Hawaii Western Management Group Commercial	$92.15
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$40.74
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$40.74
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$40.74
Rate for Payer: Ohana Health Plan Medicare	$40.74
Rate for Payer: UnitedHealthcare Medicare	$40.74
Rate for Payer: University Health Alliance Commercial	$70.70

TELFA 3X8 STERILE

Facility

$97.00

Hospital Charge Code	8341
Hospital Revenue Code	272
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$63.05
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

Know your out-of-pocket cost for care.

All Charges