Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

atorvastatin 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904629061
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

atorvastatin 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904629061
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

atorvastatin 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904629161
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

atorvastatin 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904629161
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

atorvastatin 40 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904629261
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

atorvastatin 40 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904629261
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

atorvastatin 80 mg Tab [KMC]

Facility

$22.84

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$9.59
Max. Negotiated Rate	$22.15
Rate for Payer: AlohaCare Medicaid	$11.42
Rate for Payer: AlohaCare Medicare	$9.59
Rate for Payer: Cash Price	$14.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.01
Rate for Payer: Devoted Health Medicare	$9.59
Rate for Payer: Hawaii Medical Service Association Medicare	$9.59
Rate for Payer: Hawaii Western Management Group Commercial	$21.70
Rate for Payer: Health Management Network Commercial	$19.41
Rate for Payer: Humana Medicare	$9.59
Rate for Payer: Kaiser Permanente Commercial	$20.56
Rate for Payer: Kaiser Permanente Medicaid	$11.65
Rate for Payer: Kaiser Permanente Medicare	$9.59
Rate for Payer: MDX Hawaii PPO	$22.15
Rate for Payer: Ohana Health Plan Medicaid	$9.59
Rate for Payer: Ohana Health Plan Medicare	$9.59
Rate for Payer: UnitedHealthcare Medicare	$9.59
Rate for Payer: University Health Alliance Commercial	$16.65

atorvastatin 80 mg Tab [KMC]

Facility

$22.84

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$19.41
Max. Negotiated Rate	$22.15
Rate for Payer: Cash Price	$14.85
Rate for Payer: Health Management Network Commercial	$19.41
Rate for Payer: Kaiser Permanente Commercial	$20.56
Rate for Payer: MDX Hawaii PPO	$22.15

atovaquone 1500 mg/10 mL Susp [KMC]

Facility

$26.86

Service Code	NDC 72603024801
Hospital Revenue Code	250
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$26.05
Rate for Payer: AlohaCare Medicaid	$13.43
Rate for Payer: AlohaCare Medicare	$11.28
Rate for Payer: Cash Price	$17.46
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$24.71
Rate for Payer: Devoted Health Medicare	$11.28
Rate for Payer: Hawaii Medical Service Association Medicare	$11.28
Rate for Payer: Hawaii Western Management Group Commercial	$25.52
Rate for Payer: Health Management Network Commercial	$22.83
Rate for Payer: Humana Medicare	$11.28
Rate for Payer: Kaiser Permanente Commercial	$24.17
Rate for Payer: Kaiser Permanente Medicaid	$13.70
Rate for Payer: Kaiser Permanente Medicare	$11.28
Rate for Payer: MDX Hawaii PPO	$26.05
Rate for Payer: Ohana Health Plan Medicaid	$11.28
Rate for Payer: Ohana Health Plan Medicare	$11.28
Rate for Payer: UnitedHealthcare Medicaid	$16.12
Rate for Payer: UnitedHealthcare Medicare	$11.28
Rate for Payer: University Health Alliance Commercial	$19.58

atovaquone 1500 mg/10 mL Susp [KMC]

Facility

$26.86

Service Code	NDC 72603024801
Hospital Revenue Code	250
Min. Negotiated Rate	$22.83
Max. Negotiated Rate	$26.05
Rate for Payer: Cash Price	$17.46
Rate for Payer: Health Management Network Commercial	$22.83
Rate for Payer: Kaiser Permanente Commercial	$24.17
Rate for Payer: MDX Hawaii PPO	$26.05

ATRIUM WATER SEAL CHEST DRAIN

Facility

$68.00

Hospital Charge Code	8431
Hospital Revenue Code	270
Min. Negotiated Rate	$28.56
Max. Negotiated Rate	$65.96
Rate for Payer: AlohaCare Medicaid	$34.00
Rate for Payer: AlohaCare Medicare	$28.56
Rate for Payer: Cash Price	$44.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$62.56
Rate for Payer: Devoted Health Medicare	$28.56
Rate for Payer: Hawaii Medical Service Association Medicare	$28.56
Rate for Payer: Hawaii Western Management Group Commercial	$64.60
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Humana Medicare	$28.56
Rate for Payer: Kaiser Permanente Commercial	$61.20
Rate for Payer: Kaiser Permanente Medicaid	$34.68
Rate for Payer: Kaiser Permanente Medicare	$28.56
Rate for Payer: MDX Hawaii PPO	$65.96
Rate for Payer: Ohana Health Plan Medicaid	$28.56
Rate for Payer: Ohana Health Plan Medicare	$28.56
Rate for Payer: UnitedHealthcare Medicare	$28.56
Rate for Payer: University Health Alliance Commercial	$49.57

ATRIUM WATER SEAL CHEST DRAIN

Facility

$68.00

Hospital Charge Code	8431
Hospital Revenue Code	270
Min. Negotiated Rate	$57.80
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$44.20
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$61.20
Rate for Payer: MDX Hawaii PPO	$65.96

atropine 1mg/10mL Injectable Soln [KMC]

Facility

$31.92

Service Code	HCPCS J0461
Hospital Revenue Code	636
Min. Negotiated Rate	$27.13
Max. Negotiated Rate	$30.96
Rate for Payer: Cash Price	$20.75
Rate for Payer: Health Management Network Commercial	$27.13
Rate for Payer: Kaiser Permanente Commercial	$28.73
Rate for Payer: MDX Hawaii PPO	$30.96

atropine 1mg/10mL Injectable Soln [KMC]

Facility

$31.92

Service Code	HCPCS J0461
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$30.96
Rate for Payer: AlohaCare Medicaid	$15.96
Rate for Payer: AlohaCare Medicare	$13.41
Rate for Payer: Cash Price	$20.75
Rate for Payer: Cash Price	$20.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$29.37
Rate for Payer: Devoted Health Medicare	$13.41
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.07
Rate for Payer: Hawaii Medical Service Association Medicare	$13.41
Rate for Payer: Hawaii Western Management Group Commercial	$30.32
Rate for Payer: Health Management Network Commercial	$27.13
Rate for Payer: Humana Medicare	$13.41
Rate for Payer: Kaiser Permanente Commercial	$28.73
Rate for Payer: Kaiser Permanente Medicaid	$16.28
Rate for Payer: Kaiser Permanente Medicare	$13.41
Rate for Payer: MDX Hawaii PPO	$30.96
Rate for Payer: Ohana Health Plan Medicaid	$13.41
Rate for Payer: Ohana Health Plan Medicare	$13.41
Rate for Payer: UnitedHealthcare Medicaid	$19.15
Rate for Payer: UnitedHealthcare Medicare	$13.41
Rate for Payer: University Health Alliance Commercial	$23.27

atropine-diphenoxylate 0.025 mg-2.5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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

atropine-diphenoxylate 0.025 mg-2.5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

atropine/hyoscyamine/PB/scopolamine Oral Elix 120 mL [KMC]

Facility

$3.70

Service Code	NDC 66213042304
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$3.59
Rate for Payer: Cash Price	$2.41
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$3.33
Rate for Payer: MDX Hawaii PPO	$3.59

atropine/hyoscyamine/PB/scopolamine Oral Elix 120 mL [KMC]

Facility

$3.70

Service Code	NDC 66213042304
Hospital Revenue Code	250
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$3.59
Rate for Payer: AlohaCare Medicaid	$1.85
Rate for Payer: AlohaCare Medicare	$1.55
Rate for Payer: Cash Price	$2.41
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.40
Rate for Payer: Devoted Health Medicare	$1.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1.55
Rate for Payer: Hawaii Western Management Group Commercial	$3.52
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Humana Medicare	$1.55
Rate for Payer: Kaiser Permanente Commercial	$3.33
Rate for Payer: Kaiser Permanente Medicaid	$1.89
Rate for Payer: Kaiser Permanente Medicare	$1.55
Rate for Payer: MDX Hawaii PPO	$3.59
Rate for Payer: Ohana Health Plan Medicaid	$1.55
Rate for Payer: Ohana Health Plan Medicare	$1.55
Rate for Payer: UnitedHealthcare Medicaid	$2.22
Rate for Payer: UnitedHealthcare Medicare	$1.55
Rate for Payer: University Health Alliance Commercial	$2.70

atropine Ophth 1% Sol [KMC]

Facility

$13.46

Service Code	NDC 24208075060
Hospital Revenue Code	250
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$13.06
Rate for Payer: Cash Price	$8.75
Rate for Payer: Health Management Network Commercial	$11.44
Rate for Payer: Kaiser Permanente Commercial	$12.11
Rate for Payer: MDX Hawaii PPO	$13.06

atropine Ophth 1% Sol [KMC]

Facility

$13.46

Service Code	NDC 24208075060
Hospital Revenue Code	250
Min. Negotiated Rate	$5.65
Max. Negotiated Rate	$13.06
Rate for Payer: AlohaCare Medicaid	$6.73
Rate for Payer: AlohaCare Medicare	$5.65
Rate for Payer: Cash Price	$8.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.38
Rate for Payer: Devoted Health Medicare	$5.65
Rate for Payer: Hawaii Medical Service Association Medicare	$5.65
Rate for Payer: Hawaii Western Management Group Commercial	$12.79
Rate for Payer: Health Management Network Commercial	$11.44
Rate for Payer: Humana Medicare	$5.65
Rate for Payer: Kaiser Permanente Commercial	$12.11
Rate for Payer: Kaiser Permanente Medicaid	$6.86
Rate for Payer: Kaiser Permanente Medicare	$5.65
Rate for Payer: MDX Hawaii PPO	$13.06
Rate for Payer: Ohana Health Plan Medicaid	$5.65
Rate for Payer: Ohana Health Plan Medicare	$5.65
Rate for Payer: UnitedHealthcare Medicaid	$8.08
Rate for Payer: UnitedHealthcare Medicare	$5.65
Rate for Payer: University Health Alliance Commercial	$9.81

ATTEN CURRENT STATUS

Professional

Both

$0.01

Service Code	HCPCS G9165
Hospital Revenue Code	440
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

ATTEN D/C STATUS

Professional

Both

$0.01

Service Code	HCPCS G9167
Hospital Revenue Code	440
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

ATTEN GOAL STATUS

Professional

Both

$0.01

Service Code	HCPCS G9166
Hospital Revenue Code	440
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC

Facility

$228,961.32

Service Code	MSDRG 016
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$228,961.32
Rate for Payer: Hawaii Medical Service Association Commercial	$228,961.32
Rate for Payer: University Health Alliance Commercial	$10,400.00

AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC

Facility

$228,961.32

Service Code	MSDRG 017
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$228,961.32
Rate for Payer: Hawaii Medical Service Association Commercial	$228,961.32
Rate for Payer: University Health Alliance Commercial	$10,400.00

Know your out-of-pocket cost for care.

All Charges