Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

topiramate 25 mg Tab [KMC]

Facility

$10.10

Service Code	NDC 69097012203
Hospital Revenue Code	250
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$9.80
Rate for Payer: Cash Price	$6.56
Rate for Payer: Health Management Network Commercial	$8.59
Rate for Payer: Kaiser Permanente Commercial	$9.09
Rate for Payer: MDX Hawaii PPO	$9.80

topiramate 25 mg Tab [KMC]

Facility

$10.10

Service Code	NDC 69097012203
Hospital Revenue Code	250
Min. Negotiated Rate	$4.24
Max. Negotiated Rate	$9.80
Rate for Payer: AlohaCare Medicaid	$5.05
Rate for Payer: AlohaCare Medicare	$4.24
Rate for Payer: Cash Price	$6.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.29
Rate for Payer: Devoted Health Medicare	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$4.24
Rate for Payer: Hawaii Western Management Group Commercial	$9.60
Rate for Payer: Health Management Network Commercial	$8.59
Rate for Payer: Humana Medicare	$4.24
Rate for Payer: Kaiser Permanente Commercial	$9.09
Rate for Payer: Kaiser Permanente Medicaid	$5.15
Rate for Payer: Kaiser Permanente Medicare	$4.24
Rate for Payer: MDX Hawaii PPO	$9.80
Rate for Payer: Ohana Health Plan Medicaid	$4.24
Rate for Payer: Ohana Health Plan Medicare	$4.24
Rate for Payer: UnitedHealthcare Medicaid	$6.06
Rate for Payer: UnitedHealthcare Medicare	$4.24
Rate for Payer: University Health Alliance Commercial	$7.36

torsemide 10 mg Tab

Facility

$3.00

Service Code	NDC 50111091601
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

torsemide 10 mg Tab

Facility

$3.00

Service Code	NDC 50111091601
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

torsemide 20 mg Tab [KMC]

Facility

$3.28

Service Code	NDC 31722053101
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$3.18
Rate for Payer: AlohaCare Medicaid	$1.64
Rate for Payer: AlohaCare Medicare	$1.38
Rate for Payer: Cash Price	$2.13
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.02
Rate for Payer: Devoted Health Medicare	$1.38
Rate for Payer: Hawaii Medical Service Association Medicare	$1.38
Rate for Payer: Hawaii Western Management Group Commercial	$3.12
Rate for Payer: Health Management Network Commercial	$2.79
Rate for Payer: Humana Medicare	$1.38
Rate for Payer: Kaiser Permanente Commercial	$2.95
Rate for Payer: Kaiser Permanente Medicaid	$1.67
Rate for Payer: Kaiser Permanente Medicare	$1.38
Rate for Payer: MDX Hawaii PPO	$3.18
Rate for Payer: Ohana Health Plan Medicaid	$1.38
Rate for Payer: Ohana Health Plan Medicare	$1.38
Rate for Payer: UnitedHealthcare Medicaid	$1.97
Rate for Payer: UnitedHealthcare Medicare	$1.38
Rate for Payer: University Health Alliance Commercial	$2.39

torsemide 20 mg Tab [KMC]

Facility

$3.28

Service Code	NDC 31722053101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$3.18
Rate for Payer: Cash Price	$2.13
Rate for Payer: Health Management Network Commercial	$2.79
Rate for Payer: Kaiser Permanente Commercial	$2.95
Rate for Payer: MDX Hawaii PPO	$3.18

Total Protein, CSF DLS

Facility

$38.00

Service Code	HCPCS 84157
Hospital Charge Code	422841575
Hospital Revenue Code	301
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$36.86
Rate for Payer: Cash Price	$24.70
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: MDX Hawaii PPO	$36.86

Total Protein, CSF DLS

Facility

$38.00

Service Code	HCPCS 84157
Hospital Charge Code	422841575
Hospital Revenue Code	301
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$36.86
Rate for Payer: AlohaCare Medicaid	$19.00
Rate for Payer: AlohaCare Medicare	$15.96
Rate for Payer: Cash Price	$24.70
Rate for Payer: Cash Price	$24.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.96
Rate for Payer: Devoted Health Medicare	$15.96
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$5.00
Rate for Payer: Hawaii Medical Service Association Medicare	$15.96
Rate for Payer: Hawaii Western Management Group Commercial	$4.00
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Humana Medicare	$15.96
Rate for Payer: Kaiser Permanente Commercial	$34.20
Rate for Payer: Kaiser Permanente Medicaid	$19.38
Rate for Payer: Kaiser Permanente Medicare	$15.96
Rate for Payer: MDX Hawaii PPO	$36.86
Rate for Payer: Ohana Health Plan Medicaid	$15.96
Rate for Payer: Ohana Health Plan Medicare	$15.96
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$15.96
Rate for Payer: University Health Alliance Commercial	$9.47

TRACHEAL TUBE 4.0

Facility

$23.00

Hospital Charge Code	8352
Hospital Revenue Code	272
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

TRACHEAL TUBE 4.0

Facility

$23.00

Hospital Charge Code	8352
Hospital Revenue Code	272
Min. Negotiated Rate	$9.66
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$9.66
Rate for Payer: Cash Price	$14.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.16
Rate for Payer: Devoted Health Medicare	$9.66
Rate for Payer: Hawaii Medical Service Association Medicare	$9.66
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$9.66
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$9.66
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$9.66
Rate for Payer: Ohana Health Plan Medicare	$9.66
Rate for Payer: UnitedHealthcare Medicare	$9.66
Rate for Payer: University Health Alliance Commercial	$16.76

TRACHEAL TUBE 4.5

Facility

$7.00

Hospital Charge Code	8353
Hospital Revenue Code	272
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

TRACHEAL TUBE 4.5

Facility

$7.00

Hospital Charge Code	8353
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

TRACHEAL TUBE 5.5

Facility

$30.00

Hospital Charge Code	8355
Hospital Revenue Code	272
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$29.10
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$19.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$27.60
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Humana Medicare	$12.60
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicare	$12.60
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: Ohana Health Plan Medicaid	$12.60
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicare	$12.60
Rate for Payer: University Health Alliance Commercial	$21.87

TRACHEAL TUBE 5.5

Facility

$30.00

Hospital Charge Code	8355
Hospital Revenue Code	272
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$19.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: MDX Hawaii PPO	$29.10

TRACHEAL TUBE 6.0

Facility

$131.00

Hospital Charge Code	8356
Hospital Revenue Code	272
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$85.15
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: MDX Hawaii PPO	$127.07

TRACHEAL TUBE 6.0

Facility

$131.00

Hospital Charge Code	8356
Hospital Revenue Code	272
Min. Negotiated Rate	$55.02
Max. Negotiated Rate	$127.07
Rate for Payer: AlohaCare Medicaid	$65.50
Rate for Payer: AlohaCare Medicare	$55.02
Rate for Payer: Cash Price	$85.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$120.52
Rate for Payer: Devoted Health Medicare	$55.02
Rate for Payer: Hawaii Medical Service Association Medicare	$55.02
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Humana Medicare	$55.02
Rate for Payer: Kaiser Permanente Commercial	$117.90
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: Kaiser Permanente Medicare	$55.02
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: Ohana Health Plan Medicaid	$55.02
Rate for Payer: Ohana Health Plan Medicare	$55.02
Rate for Payer: UnitedHealthcare Medicare	$55.02
Rate for Payer: University Health Alliance Commercial	$95.49

TRACHEAL TUBE 6.5

Facility

$136.00

Hospital Charge Code	8357
Hospital Revenue Code	272
Min. Negotiated Rate	$115.60
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$88.40
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92

TRACHEAL TUBE 6.5

Facility

$136.00

Hospital Charge Code	8357
Hospital Revenue Code	272
Min. Negotiated Rate	$57.12
Max. Negotiated Rate	$131.92
Rate for Payer: AlohaCare Medicaid	$68.00
Rate for Payer: AlohaCare Medicare	$57.12
Rate for Payer: Cash Price	$88.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$125.12
Rate for Payer: Devoted Health Medicare	$57.12
Rate for Payer: Hawaii Medical Service Association Medicare	$57.12
Rate for Payer: Hawaii Western Management Group Commercial	$129.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Humana Medicare	$57.12
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicare	$57.12
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: Ohana Health Plan Medicaid	$57.12
Rate for Payer: Ohana Health Plan Medicare	$57.12
Rate for Payer: UnitedHealthcare Medicare	$57.12
Rate for Payer: University Health Alliance Commercial	$99.13

TRACHEAL TUBE 7.0

Facility

$7.00

Hospital Charge Code	8358
Hospital Revenue Code	272
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

TRACHEAL TUBE 7.0

Facility

$7.00

Hospital Charge Code	8358
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

TRACHEAL TUBE 7.5

Facility

$7.00

Hospital Charge Code	8359
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

TRACHEAL TUBE 7.5

Facility

$7.00

Hospital Charge Code	8359
Hospital Revenue Code	272
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

TRACHEAL TUBE 8.0

Facility

$7.00

Hospital Charge Code	8360
Hospital Revenue Code	272
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

TRACHEAL TUBE 8.0

Facility

$7.00

Hospital Charge Code	8360
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

TRACHEAL TUBE 8.5

Facility

$7.00

Hospital Charge Code	8361
Hospital Revenue Code	272
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

Know your out-of-pocket cost for care.

All Charges