Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

tiotropium 18 mcg INHALED Cap [KMC]

Facility

$81.92

Service Code	NDC 00597007541
Hospital Revenue Code	250
Min. Negotiated Rate	$34.41
Max. Negotiated Rate	$79.46
Rate for Payer: AlohaCare Medicaid	$40.96
Rate for Payer: AlohaCare Medicare	$34.41
Rate for Payer: Cash Price	$53.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$75.37
Rate for Payer: Devoted Health Medicare	$34.41
Rate for Payer: Hawaii Medical Service Association Medicare	$34.41
Rate for Payer: Hawaii Western Management Group Commercial	$77.82
Rate for Payer: Health Management Network Commercial	$69.63
Rate for Payer: Humana Medicare	$34.41
Rate for Payer: Kaiser Permanente Commercial	$73.73
Rate for Payer: Kaiser Permanente Medicaid	$41.78
Rate for Payer: Kaiser Permanente Medicare	$34.41
Rate for Payer: MDX Hawaii PPO	$79.46
Rate for Payer: Ohana Health Plan Medicaid	$34.41
Rate for Payer: Ohana Health Plan Medicare	$34.41
Rate for Payer: UnitedHealthcare Medicaid	$49.15
Rate for Payer: UnitedHealthcare Medicare	$34.41
Rate for Payer: University Health Alliance Commercial	$59.71

tiotropium 18 mcg INHALED Cap [KMC]

Facility

$81.92

Service Code	NDC 00597007541
Hospital Revenue Code	250
Min. Negotiated Rate	$69.63
Max. Negotiated Rate	$79.46
Rate for Payer: Cash Price	$53.25
Rate for Payer: Health Management Network Commercial	$69.63
Rate for Payer: Kaiser Permanente Commercial	$73.73
Rate for Payer: MDX Hawaii PPO	$79.46

tiotropium 2.5 mcg inhaler [KMC]

Facility

$573.60

Service Code	NDC 00597010061
Hospital Revenue Code	250
Min. Negotiated Rate	$487.56
Max. Negotiated Rate	$556.39
Rate for Payer: Cash Price	$372.84
Rate for Payer: Health Management Network Commercial	$487.56
Rate for Payer: Kaiser Permanente Commercial	$516.24
Rate for Payer: MDX Hawaii PPO	$556.39

tiotropium 2.5 mcg inhaler [KMC]

Facility

$573.60

Service Code	NDC 00597010061
Hospital Revenue Code	250
Min. Negotiated Rate	$240.91
Max. Negotiated Rate	$556.39
Rate for Payer: AlohaCare Medicaid	$286.80
Rate for Payer: AlohaCare Medicare	$240.91
Rate for Payer: Cash Price	$372.84
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$527.71
Rate for Payer: Devoted Health Medicare	$240.91
Rate for Payer: Hawaii Medical Service Association Medicare	$240.91
Rate for Payer: Hawaii Western Management Group Commercial	$544.92
Rate for Payer: Health Management Network Commercial	$487.56
Rate for Payer: Humana Medicare	$240.91
Rate for Payer: Kaiser Permanente Commercial	$516.24
Rate for Payer: Kaiser Permanente Medicaid	$292.54
Rate for Payer: Kaiser Permanente Medicare	$240.91
Rate for Payer: MDX Hawaii PPO	$556.39
Rate for Payer: Ohana Health Plan Medicaid	$240.91
Rate for Payer: Ohana Health Plan Medicare	$240.91
Rate for Payer: UnitedHealthcare Medicaid	$344.16
Rate for Payer: UnitedHealthcare Medicare	$240.91
Rate for Payer: University Health Alliance Commercial	$418.10

tiotropium-olodaterol 2.5-2.5 mcg inhaler [KMC]

Facility

$90.00

Service Code	NDC 00597015570
Hospital Revenue Code	250
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$87.30
Rate for Payer: AlohaCare Medicaid	$45.00
Rate for Payer: AlohaCare Medicare	$37.80
Rate for Payer: Cash Price	$58.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$82.80
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Hawaii Medical Service Association Medicare	$37.80
Rate for Payer: Hawaii Western Management Group Commercial	$85.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Humana Medicare	$37.80
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicare	$37.80
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: Ohana Health Plan Medicaid	$37.80
Rate for Payer: Ohana Health Plan Medicare	$37.80
Rate for Payer: UnitedHealthcare Medicaid	$54.00
Rate for Payer: UnitedHealthcare Medicare	$37.80
Rate for Payer: University Health Alliance Commercial	$65.60

tiotropium-olodaterol 2.5-2.5 mcg inhaler [KMC]

Facility

$90.00

Service Code	NDC 00597015570
Hospital Revenue Code	250
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: MDX Hawaii PPO	$87.30

tirzepatide 15 mg/0.5 mL Soln [KMC]

Facility

$2,565.79

Service Code	NDC 00002145780
Hospital Revenue Code	250
Min. Negotiated Rate	$2,180.92
Max. Negotiated Rate	$2,488.82
Rate for Payer: Cash Price	$1,667.76
Rate for Payer: Health Management Network Commercial	$2,180.92
Rate for Payer: Kaiser Permanente Commercial	$2,309.21
Rate for Payer: MDX Hawaii PPO	$2,488.82

tirzepatide 15 mg/0.5 mL Soln [KMC]

Facility

$2,565.79

Service Code	NDC 00002145780
Hospital Revenue Code	250
Min. Negotiated Rate	$1,077.63
Max. Negotiated Rate	$2,488.82
Rate for Payer: AlohaCare Medicaid	$1,282.89
Rate for Payer: AlohaCare Medicare	$1,077.63
Rate for Payer: Cash Price	$1,667.76
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,360.53
Rate for Payer: Devoted Health Medicare	$1,077.63
Rate for Payer: Hawaii Medical Service Association Medicare	$1,077.63
Rate for Payer: Hawaii Western Management Group Commercial	$2,437.50
Rate for Payer: Health Management Network Commercial	$2,180.92
Rate for Payer: Humana Medicare	$1,077.63
Rate for Payer: Kaiser Permanente Commercial	$2,309.21
Rate for Payer: Kaiser Permanente Medicaid	$1,308.55
Rate for Payer: Kaiser Permanente Medicare	$1,077.63
Rate for Payer: MDX Hawaii PPO	$2,488.82
Rate for Payer: Ohana Health Plan Medicaid	$1,077.63
Rate for Payer: Ohana Health Plan Medicare	$1,077.63
Rate for Payer: UnitedHealthcare Medicaid	$1,539.47
Rate for Payer: UnitedHealthcare Medicare	$1,077.63
Rate for Payer: University Health Alliance Commercial	$1,870.20

tirzepatide 2.5 mg/0.5 mL Soln [KMC]

Facility

$2,607.29

Service Code	NDC 00002250680
Hospital Revenue Code	250
Min. Negotiated Rate	$1,095.06
Max. Negotiated Rate	$2,529.07
Rate for Payer: AlohaCare Medicaid	$1,303.64
Rate for Payer: AlohaCare Medicare	$1,095.06
Rate for Payer: Cash Price	$1,694.74
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,398.71
Rate for Payer: Devoted Health Medicare	$1,095.06
Rate for Payer: Hawaii Medical Service Association Medicare	$1,095.06
Rate for Payer: Hawaii Western Management Group Commercial	$2,476.93
Rate for Payer: Health Management Network Commercial	$2,216.20
Rate for Payer: Humana Medicare	$1,095.06
Rate for Payer: Kaiser Permanente Commercial	$2,346.56
Rate for Payer: Kaiser Permanente Medicaid	$1,329.72
Rate for Payer: Kaiser Permanente Medicare	$1,095.06
Rate for Payer: MDX Hawaii PPO	$2,529.07
Rate for Payer: Ohana Health Plan Medicaid	$1,095.06
Rate for Payer: Ohana Health Plan Medicare	$1,095.06
Rate for Payer: UnitedHealthcare Medicaid	$1,564.37
Rate for Payer: UnitedHealthcare Medicare	$1,095.06
Rate for Payer: University Health Alliance Commercial	$1,900.45

tirzepatide 2.5 mg/0.5 mL Soln [KMC]

Facility

$2,607.29

Service Code	NDC 00002250680
Hospital Revenue Code	250
Min. Negotiated Rate	$2,216.20
Max. Negotiated Rate	$2,529.07
Rate for Payer: Cash Price	$1,694.74
Rate for Payer: Health Management Network Commercial	$2,216.20
Rate for Payer: Kaiser Permanente Commercial	$2,346.56
Rate for Payer: MDX Hawaii PPO	$2,529.07

tirzepatide 5 mg/0.5 mL Soln [KMC]

Facility

$2,455.30

Service Code	NDC 00002149580
Hospital Revenue Code	250
Min. Negotiated Rate	$1,031.23
Max. Negotiated Rate	$2,381.64
Rate for Payer: AlohaCare Medicaid	$1,227.65
Rate for Payer: AlohaCare Medicare	$1,031.23
Rate for Payer: Cash Price	$1,595.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,258.88
Rate for Payer: Devoted Health Medicare	$1,031.23
Rate for Payer: Hawaii Medical Service Association Medicare	$1,031.23
Rate for Payer: Hawaii Western Management Group Commercial	$2,332.53
Rate for Payer: Health Management Network Commercial	$2,087.01
Rate for Payer: Humana Medicare	$1,031.23
Rate for Payer: Kaiser Permanente Commercial	$2,209.77
Rate for Payer: Kaiser Permanente Medicaid	$1,252.20
Rate for Payer: Kaiser Permanente Medicare	$1,031.23
Rate for Payer: MDX Hawaii PPO	$2,381.64
Rate for Payer: Ohana Health Plan Medicaid	$1,031.23
Rate for Payer: Ohana Health Plan Medicare	$1,031.23
Rate for Payer: UnitedHealthcare Medicaid	$1,473.18
Rate for Payer: UnitedHealthcare Medicare	$1,031.23
Rate for Payer: University Health Alliance Commercial	$1,789.67

tirzepatide 5 mg/0.5 mL Soln [KMC]

Facility

$2,455.30

Service Code	NDC 00002149580
Hospital Revenue Code	250
Min. Negotiated Rate	$2,087.01
Max. Negotiated Rate	$2,381.64
Rate for Payer: Cash Price	$1,595.95
Rate for Payer: Health Management Network Commercial	$2,087.01
Rate for Payer: Kaiser Permanente Commercial	$2,209.77
Rate for Payer: MDX Hawaii PPO	$2,381.64

tirzepatide 7.5 mg/0.5 mL Soln [KMC]

Facility

$2,591.45

Service Code	NDC 00002148480
Hospital Revenue Code	250
Min. Negotiated Rate	$1,088.41
Max. Negotiated Rate	$2,513.71
Rate for Payer: AlohaCare Medicaid	$1,295.72
Rate for Payer: AlohaCare Medicare	$1,088.41
Rate for Payer: Cash Price	$1,684.44
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,384.13
Rate for Payer: Devoted Health Medicare	$1,088.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1,088.41
Rate for Payer: Hawaii Western Management Group Commercial	$2,461.88
Rate for Payer: Health Management Network Commercial	$2,202.73
Rate for Payer: Humana Medicare	$1,088.41
Rate for Payer: Kaiser Permanente Commercial	$2,332.30
Rate for Payer: Kaiser Permanente Medicaid	$1,321.64
Rate for Payer: Kaiser Permanente Medicare	$1,088.41
Rate for Payer: MDX Hawaii PPO	$2,513.71
Rate for Payer: Ohana Health Plan Medicaid	$1,088.41
Rate for Payer: Ohana Health Plan Medicare	$1,088.41
Rate for Payer: UnitedHealthcare Medicaid	$1,554.87
Rate for Payer: UnitedHealthcare Medicare	$1,088.41
Rate for Payer: University Health Alliance Commercial	$1,888.91

tirzepatide 7.5 mg/0.5 mL Soln [KMC]

Facility

$2,591.45

Service Code	NDC 00002148480
Hospital Revenue Code	250
Min. Negotiated Rate	$2,202.73
Max. Negotiated Rate	$2,513.71
Rate for Payer: Cash Price	$1,684.44
Rate for Payer: Health Management Network Commercial	$2,202.73
Rate for Payer: Kaiser Permanente Commercial	$2,332.30
Rate for Payer: MDX Hawaii PPO	$2,513.71

Tissue Culture and Gram Stain DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

Tissue Culture and Gram Stain DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$54.18
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.68
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$54.18
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$54.18
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$54.18
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$54.18
Rate for Payer: Ohana Health Plan Medicare	$54.18
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$54.18
Rate for Payer: University Health Alliance Commercial	$22.26

TISSUE CULTURE LYMPHOCYTE DLS

Facility

$1,297.00

Service Code	HCPCS 88230
Hospital Charge Code	422882305
Hospital Revenue Code	300
Min. Negotiated Rate	$1,102.45
Max. Negotiated Rate	$1,258.09
Rate for Payer: Cash Price	$843.05
Rate for Payer: Health Management Network Commercial	$1,102.45
Rate for Payer: Kaiser Permanente Commercial	$1,167.30
Rate for Payer: MDX Hawaii PPO	$1,258.09

TISSUE CULTURE LYMPHOCYTE DLS

Facility

$1,297.00

Service Code	HCPCS 88230
Hospital Charge Code	422882305
Hospital Revenue Code	300
Min. Negotiated Rate	$116.49
Max. Negotiated Rate	$1,258.09
Rate for Payer: AlohaCare Medicaid	$648.50
Rate for Payer: AlohaCare Medicare	$544.74
Rate for Payer: Cash Price	$843.05
Rate for Payer: Cash Price	$843.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,193.24
Rate for Payer: Devoted Health Medicare	$544.74
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$161.00
Rate for Payer: Hawaii Medical Service Association Commercial	$145.61
Rate for Payer: Hawaii Medical Service Association Medicare	$544.74
Rate for Payer: Hawaii Western Management Group Commercial	$116.49
Rate for Payer: Health Management Network Commercial	$1,102.45
Rate for Payer: Humana Medicare	$544.74
Rate for Payer: Kaiser Permanente Commercial	$1,167.30
Rate for Payer: Kaiser Permanente Medicaid	$661.47
Rate for Payer: Kaiser Permanente Medicare	$544.74
Rate for Payer: MDX Hawaii PPO	$1,258.09
Rate for Payer: Ohana Health Plan Medicaid	$544.74
Rate for Payer: Ohana Health Plan Medicare	$544.74
Rate for Payer: UnitedHealthcare Medicaid	$161.00
Rate for Payer: UnitedHealthcare Medicare	$544.74
Rate for Payer: University Health Alliance Commercial	$301.12

Tissue Transglutaminase Ab, IgA DLS

Facility

$256.00

Service Code	HCPCS 83516
Hospital Charge Code	422835165
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$248.32
Rate for Payer: AlohaCare Medicaid	$128.00
Rate for Payer: AlohaCare Medicare	$107.52
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$235.52
Rate for Payer: Devoted Health Medicare	$107.52
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$107.52
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Humana Medicare	$107.52
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: Kaiser Permanente Medicaid	$130.56
Rate for Payer: Kaiser Permanente Medicare	$107.52
Rate for Payer: MDX Hawaii PPO	$248.32
Rate for Payer: Ohana Health Plan Medicaid	$107.52
Rate for Payer: Ohana Health Plan Medicare	$107.52
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$107.52
Rate for Payer: University Health Alliance Commercial	$29.82

Tissue Transglutaminase Ab, IgA DLS

Facility

$256.00

Service Code	HCPCS 83516
Hospital Charge Code	422835165
Hospital Revenue Code	301
Min. Negotiated Rate	$217.60
Max. Negotiated Rate	$248.32
Rate for Payer: Cash Price	$166.40
Rate for Payer: Health Management Network Commercial	$217.60
Rate for Payer: Kaiser Permanente Commercial	$230.40
Rate for Payer: MDX Hawaii PPO	$248.32

tiZANidine 2 mg Tab [KMC]

Facility

$4.89

Service Code	NDC 16714017101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$4.74
Rate for Payer: Cash Price	$3.18
Rate for Payer: Health Management Network Commercial	$4.16
Rate for Payer: Kaiser Permanente Commercial	$4.40
Rate for Payer: MDX Hawaii PPO	$4.74

tiZANidine 2 mg Tab [KMC]

Facility

$4.89

Service Code	NDC 16714017101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$4.74
Rate for Payer: AlohaCare Medicaid	$2.44
Rate for Payer: AlohaCare Medicare	$2.05
Rate for Payer: Cash Price	$3.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.50
Rate for Payer: Devoted Health Medicare	$2.05
Rate for Payer: Hawaii Medical Service Association Medicare	$2.05
Rate for Payer: Hawaii Western Management Group Commercial	$4.65
Rate for Payer: Health Management Network Commercial	$4.16
Rate for Payer: Humana Medicare	$2.05
Rate for Payer: Kaiser Permanente Commercial	$4.40
Rate for Payer: Kaiser Permanente Medicaid	$2.49
Rate for Payer: Kaiser Permanente Medicare	$2.05
Rate for Payer: MDX Hawaii PPO	$4.74
Rate for Payer: Ohana Health Plan Medicaid	$2.05
Rate for Payer: Ohana Health Plan Medicare	$2.05
Rate for Payer: UnitedHealthcare Medicaid	$2.93
Rate for Payer: UnitedHealthcare Medicare	$2.05
Rate for Payer: University Health Alliance Commercial	$3.56

tiZANidine 4 mg Tab [KMC]

Facility

$5.86

Service Code	NDC 29300016915
Hospital Revenue Code	250
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$5.68
Rate for Payer: AlohaCare Medicaid	$2.93
Rate for Payer: AlohaCare Medicare	$2.46
Rate for Payer: Cash Price	$3.81
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.39
Rate for Payer: Devoted Health Medicare	$2.46
Rate for Payer: Hawaii Medical Service Association Medicare	$2.46
Rate for Payer: Hawaii Western Management Group Commercial	$5.57
Rate for Payer: Health Management Network Commercial	$4.98
Rate for Payer: Humana Medicare	$2.46
Rate for Payer: Kaiser Permanente Commercial	$5.27
Rate for Payer: Kaiser Permanente Medicaid	$2.99
Rate for Payer: Kaiser Permanente Medicare	$2.46
Rate for Payer: MDX Hawaii PPO	$5.68
Rate for Payer: Ohana Health Plan Medicaid	$2.46
Rate for Payer: Ohana Health Plan Medicare	$2.46
Rate for Payer: UnitedHealthcare Medicaid	$3.52
Rate for Payer: UnitedHealthcare Medicare	$2.46
Rate for Payer: University Health Alliance Commercial	$4.27

tiZANidine 4 mg Tab [KMC]

Facility

$5.86

Service Code	NDC 29300016915
Hospital Revenue Code	250
Min. Negotiated Rate	$4.98
Max. Negotiated Rate	$5.68
Rate for Payer: Cash Price	$3.81
Rate for Payer: Health Management Network Commercial	$4.98
Rate for Payer: Kaiser Permanente Commercial	$5.27
Rate for Payer: MDX Hawaii PPO	$5.68

tiZANidine 6 mg Cap [KMC]

Facility

$20.62

Service Code	NDC 70710111308
Hospital Revenue Code	250
Min. Negotiated Rate	$17.53
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$13.40
Rate for Payer: Health Management Network Commercial	$17.53
Rate for Payer: Kaiser Permanente Commercial	$18.56
Rate for Payer: MDX Hawaii PPO	$20.00

Know your out-of-pocket cost for care.

All Charges