Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

AUTOMATIC GAS POWERED RESUSCITATOR

Facility

$4.00

Hospital Charge Code	8028
Hospital Revenue Code	270
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

AUTOMATIC GAS POWERED RESUSCITATOR

Facility

$4.00

Hospital Charge Code	8028
Hospital Revenue Code	270
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

AVUL NAIL PLATE SIMPLE ED Charge

Facility

$754.00

Service Code	HCPCS 11730
Hospital Charge Code	440117300
Hospital Revenue Code	450
Min. Negotiated Rate	$316.68
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$377.00
Rate for Payer: AlohaCare Medicare	$316.68
Rate for Payer: Cash Price	$490.10
Rate for Payer: Cash Price	$490.10
Rate for Payer: Cash Price	$490.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$693.68
Rate for Payer: Devoted Health Medicare	$316.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$316.68
Rate for Payer: Hawaii Western Management Group Commercial	$716.30
Rate for Payer: Health Management Network Commercial	$640.90
Rate for Payer: Humana Medicare	$316.68
Rate for Payer: Kaiser Permanente Commercial	$678.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$316.68
Rate for Payer: MDX Hawaii PPO	$731.38
Rate for Payer: Ohana Health Plan Medicaid	$316.68
Rate for Payer: Ohana Health Plan Medicare	$316.68
Rate for Payer: UnitedHealthcare Medicare	$316.68
Rate for Payer: University Health Alliance Commercial	$4,035.20

AVUL NAIL PLATE SIMPLE ED Charge

Facility

$754.00

Service Code	HCPCS 11730
Hospital Charge Code	440117300
Hospital Revenue Code	450
Min. Negotiated Rate	$640.90
Max. Negotiated Rate	$731.38
Rate for Payer: Cash Price	$490.10
Rate for Payer: Health Management Network Commercial	$640.90
Rate for Payer: Kaiser Permanente Commercial	$678.60
Rate for Payer: MDX Hawaii PPO	$731.38

AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1

Professional

Both

$149.00

Service Code	HCPCS 11730
Hospital Revenue Code	361
Min. Negotiated Rate	$49.29
Max. Negotiated Rate	$126.65
Rate for Payer: AlohaCare Medicaid	$54.23
Rate for Payer: AlohaCare Medicare	$49.29
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$49.29
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$54.23
Rate for Payer: Hawaii Medical Service Association Commercial	$83.72
Rate for Payer: Hawaii Medical Service Association Medicare	$49.29
Rate for Payer: Hawaii Western Management Group Commercial	$50.18
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$59.15
Rate for Payer: Kaiser Permanente Medicaid	$59.15
Rate for Payer: Kaiser Permanente Medicare	$59.15
Rate for Payer: Ohana Health Plan Medicaid	$54.23
Rate for Payer: Ohana Health Plan Medicare	$49.29
Rate for Payer: UnitedHealthcare Medicaid	$54.23
Rate for Payer: UnitedHealthcare Medicare	$49.29
Rate for Payer: University Health Alliance Commercial	$59.12

AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL

Professional

Both

$60.00

Service Code	HCPCS 11732
Hospital Revenue Code	361
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$51.00
Rate for Payer: AlohaCare Medicaid	$16.65
Rate for Payer: AlohaCare Medicare	$14.84
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Devoted Health Medicare	$14.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.65
Rate for Payer: Hawaii Medical Service Association Commercial	$38.70
Rate for Payer: Hawaii Medical Service Association Medicare	$14.84
Rate for Payer: Hawaii Western Management Group Commercial	$9.62
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$17.81
Rate for Payer: Kaiser Permanente Medicaid	$17.81
Rate for Payer: Kaiser Permanente Medicare	$17.81
Rate for Payer: Ohana Health Plan Medicaid	$16.65
Rate for Payer: Ohana Health Plan Medicare	$14.84
Rate for Payer: UnitedHealthcare Medicaid	$16.65
Rate for Payer: UnitedHealthcare Medicare	$14.84
Rate for Payer: University Health Alliance Commercial	$17.96

azaTHIOprine 50 mg Tab [KMC]

Facility

$27.24

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$26.42
Rate for Payer: AlohaCare Medicaid	$13.62
Rate for Payer: AlohaCare Medicare	$11.44
Rate for Payer: Cash Price	$17.71
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$25.06
Rate for Payer: Devoted Health Medicare	$11.44
Rate for Payer: Hawaii Medical Service Association Medicare	$11.44
Rate for Payer: Hawaii Western Management Group Commercial	$25.88
Rate for Payer: Health Management Network Commercial	$23.15
Rate for Payer: Humana Medicare	$11.44
Rate for Payer: Kaiser Permanente Commercial	$24.52
Rate for Payer: Kaiser Permanente Medicaid	$13.89
Rate for Payer: Kaiser Permanente Medicare	$11.44
Rate for Payer: MDX Hawaii PPO	$26.42
Rate for Payer: Ohana Health Plan Medicaid	$11.44
Rate for Payer: Ohana Health Plan Medicare	$11.44
Rate for Payer: UnitedHealthcare Medicare	$11.44
Rate for Payer: University Health Alliance Commercial	$19.86

azaTHIOprine 50 mg Tab [KMC]

Facility

$27.24

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$23.15
Max. Negotiated Rate	$26.42
Rate for Payer: Cash Price	$17.71
Rate for Payer: Health Management Network Commercial	$23.15
Rate for Payer: Kaiser Permanente Commercial	$24.52
Rate for Payer: MDX Hawaii PPO	$26.42

azelastine-fluticasone 137-50 mcg Nasal Spray [KMC]

Facility

$39.62

Service Code	NDC 60505095303
Hospital Revenue Code	250
Min. Negotiated Rate	$16.64
Max. Negotiated Rate	$38.43
Rate for Payer: AlohaCare Medicaid	$19.81
Rate for Payer: AlohaCare Medicare	$16.64
Rate for Payer: Cash Price	$25.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$36.45
Rate for Payer: Devoted Health Medicare	$16.64
Rate for Payer: Hawaii Medical Service Association Medicare	$16.64
Rate for Payer: Hawaii Western Management Group Commercial	$37.64
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Humana Medicare	$16.64
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: Kaiser Permanente Medicaid	$20.21
Rate for Payer: Kaiser Permanente Medicare	$16.64
Rate for Payer: MDX Hawaii PPO	$38.43
Rate for Payer: Ohana Health Plan Medicaid	$16.64
Rate for Payer: Ohana Health Plan Medicare	$16.64
Rate for Payer: UnitedHealthcare Medicaid	$23.77
Rate for Payer: UnitedHealthcare Medicare	$16.64
Rate for Payer: University Health Alliance Commercial	$28.88

azelastine-fluticasone 137-50 mcg Nasal Spray [KMC]

Facility

$39.62

Service Code	NDC 60505095303
Hospital Revenue Code	250
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$38.43
Rate for Payer: Cash Price	$25.75
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: MDX Hawaii PPO	$38.43

azelastine Nasal 137 mcg/inh Spry [KMC]

Facility

$14.03

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$5.89
Max. Negotiated Rate	$13.61
Rate for Payer: AlohaCare Medicaid	$7.01
Rate for Payer: AlohaCare Medicare	$5.89
Rate for Payer: Cash Price	$9.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.91
Rate for Payer: Devoted Health Medicare	$5.89
Rate for Payer: Hawaii Medical Service Association Medicare	$5.89
Rate for Payer: Hawaii Western Management Group Commercial	$13.33
Rate for Payer: Health Management Network Commercial	$11.93
Rate for Payer: Humana Medicare	$5.89
Rate for Payer: Kaiser Permanente Commercial	$12.63
Rate for Payer: Kaiser Permanente Medicaid	$7.16
Rate for Payer: Kaiser Permanente Medicare	$5.89
Rate for Payer: MDX Hawaii PPO	$13.61
Rate for Payer: Ohana Health Plan Medicaid	$5.89
Rate for Payer: Ohana Health Plan Medicare	$5.89
Rate for Payer: UnitedHealthcare Medicare	$5.89
Rate for Payer: University Health Alliance Commercial	$10.23

azelastine Nasal 137 mcg/inh Spry [KMC]

Facility

$14.03

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.93
Max. Negotiated Rate	$13.61
Rate for Payer: Cash Price	$9.12
Rate for Payer: Health Management Network Commercial	$11.93
Rate for Payer: Kaiser Permanente Commercial	$12.63
Rate for Payer: MDX Hawaii PPO	$13.61

azelastine ophthalmic 0.05% Soln [KMC]

Facility

$29.17

Service Code	NDC 70069009101
Hospital Revenue Code	250
Min. Negotiated Rate	$24.79
Max. Negotiated Rate	$28.29
Rate for Payer: Cash Price	$18.96
Rate for Payer: Health Management Network Commercial	$24.79
Rate for Payer: Kaiser Permanente Commercial	$26.25
Rate for Payer: MDX Hawaii PPO	$28.29

azelastine ophthalmic 0.05% Soln [KMC]

Facility

$29.17

Service Code	NDC 70069009101
Hospital Revenue Code	250
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$28.29
Rate for Payer: AlohaCare Medicaid	$14.59
Rate for Payer: AlohaCare Medicare	$12.25
Rate for Payer: Cash Price	$18.96
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$26.84
Rate for Payer: Devoted Health Medicare	$12.25
Rate for Payer: Hawaii Medical Service Association Medicare	$12.25
Rate for Payer: Hawaii Western Management Group Commercial	$27.71
Rate for Payer: Health Management Network Commercial	$24.79
Rate for Payer: Humana Medicare	$12.25
Rate for Payer: Kaiser Permanente Commercial	$26.25
Rate for Payer: Kaiser Permanente Medicaid	$14.88
Rate for Payer: Kaiser Permanente Medicare	$12.25
Rate for Payer: MDX Hawaii PPO	$28.29
Rate for Payer: Ohana Health Plan Medicaid	$12.25
Rate for Payer: Ohana Health Plan Medicare	$12.25
Rate for Payer: UnitedHealthcare Medicaid	$17.50
Rate for Payer: UnitedHealthcare Medicare	$12.25
Rate for Payer: University Health Alliance Commercial	$21.26

azithromycin 250 mg Tab [KMC]

Facility

$31.13

Service Code	NDC 65862064169
Hospital Revenue Code	250
Min. Negotiated Rate	$13.07
Max. Negotiated Rate	$30.20
Rate for Payer: AlohaCare Medicaid	$15.56
Rate for Payer: AlohaCare Medicare	$13.07
Rate for Payer: Cash Price	$20.23
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$28.64
Rate for Payer: Devoted Health Medicare	$13.07
Rate for Payer: Hawaii Medical Service Association Medicare	$13.07
Rate for Payer: Hawaii Western Management Group Commercial	$29.57
Rate for Payer: Health Management Network Commercial	$26.46
Rate for Payer: Humana Medicare	$13.07
Rate for Payer: Kaiser Permanente Commercial	$28.02
Rate for Payer: Kaiser Permanente Medicaid	$15.88
Rate for Payer: Kaiser Permanente Medicare	$13.07
Rate for Payer: MDX Hawaii PPO	$30.20
Rate for Payer: Ohana Health Plan Medicaid	$13.07
Rate for Payer: Ohana Health Plan Medicare	$13.07
Rate for Payer: UnitedHealthcare Medicaid	$18.68
Rate for Payer: UnitedHealthcare Medicare	$13.07
Rate for Payer: University Health Alliance Commercial	$22.69

azithromycin 250 mg Tab [KMC]

Facility

$31.13

Service Code	NDC 65862064169
Hospital Revenue Code	250
Min. Negotiated Rate	$26.46
Max. Negotiated Rate	$30.20
Rate for Payer: Cash Price	$20.23
Rate for Payer: Health Management Network Commercial	$26.46
Rate for Payer: Kaiser Permanente Commercial	$28.02
Rate for Payer: MDX Hawaii PPO	$30.20

azithromycin 500 mg IV Inj [KMC]

Facility

$69.20

Service Code	HCPCS J0456
Hospital Revenue Code	636
Min. Negotiated Rate	$58.82
Max. Negotiated Rate	$67.12
Rate for Payer: Cash Price	$44.98
Rate for Payer: Health Management Network Commercial	$58.82
Rate for Payer: Kaiser Permanente Commercial	$62.28
Rate for Payer: MDX Hawaii PPO	$67.12

azithromycin 500 mg IV Inj [KMC]

Facility

$69.20

Service Code	HCPCS J0456
Hospital Revenue Code	636
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$67.12
Rate for Payer: AlohaCare Medicaid	$34.60
Rate for Payer: AlohaCare Medicare	$29.06
Rate for Payer: Cash Price	$44.98
Rate for Payer: Cash Price	$44.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.66
Rate for Payer: Devoted Health Medicare	$29.06
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.61
Rate for Payer: Hawaii Medical Service Association Medicare	$29.06
Rate for Payer: Hawaii Western Management Group Commercial	$65.74
Rate for Payer: Health Management Network Commercial	$58.82
Rate for Payer: Humana Medicare	$29.06
Rate for Payer: Kaiser Permanente Commercial	$62.28
Rate for Payer: Kaiser Permanente Medicaid	$35.29
Rate for Payer: Kaiser Permanente Medicare	$29.06
Rate for Payer: MDX Hawaii PPO	$67.12
Rate for Payer: Ohana Health Plan Medicaid	$29.06
Rate for Payer: Ohana Health Plan Medicare	$29.06
Rate for Payer: UnitedHealthcare Medicaid	$41.52
Rate for Payer: UnitedHealthcare Medicare	$29.06
Rate for Payer: University Health Alliance Commercial	$50.44

aztreonam 1 gm vial [KMC]

Facility

$158.16

Service Code	NDC 63323040126
Hospital Revenue Code	250
Min. Negotiated Rate	$134.44
Max. Negotiated Rate	$153.42
Rate for Payer: Cash Price	$102.80
Rate for Payer: Health Management Network Commercial	$134.44
Rate for Payer: Kaiser Permanente Commercial	$142.34
Rate for Payer: MDX Hawaii PPO	$153.42

aztreonam 1 gm vial [KMC]

Facility

$158.16

Service Code	NDC 63323040126
Hospital Revenue Code	250
Min. Negotiated Rate	$66.43
Max. Negotiated Rate	$153.42
Rate for Payer: AlohaCare Medicaid	$79.08
Rate for Payer: AlohaCare Medicare	$66.43
Rate for Payer: Cash Price	$102.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$145.51
Rate for Payer: Devoted Health Medicare	$66.43
Rate for Payer: Hawaii Medical Service Association Medicare	$66.43
Rate for Payer: Hawaii Western Management Group Commercial	$150.25
Rate for Payer: Health Management Network Commercial	$134.44
Rate for Payer: Humana Medicare	$66.43
Rate for Payer: Kaiser Permanente Commercial	$142.34
Rate for Payer: Kaiser Permanente Medicaid	$80.66
Rate for Payer: Kaiser Permanente Medicare	$66.43
Rate for Payer: MDX Hawaii PPO	$153.42
Rate for Payer: Ohana Health Plan Medicaid	$66.43
Rate for Payer: Ohana Health Plan Medicare	$66.43
Rate for Payer: UnitedHealthcare Medicaid	$94.90
Rate for Payer: UnitedHealthcare Medicare	$66.43
Rate for Payer: University Health Alliance Commercial	$115.28

aztreonam 2 gm vial [KMC]

Facility

$321.36

Service Code	NDC 63323040230
Hospital Revenue Code	250
Min. Negotiated Rate	$273.16
Max. Negotiated Rate	$311.72
Rate for Payer: Cash Price	$208.88
Rate for Payer: Health Management Network Commercial	$273.16
Rate for Payer: Kaiser Permanente Commercial	$289.22
Rate for Payer: MDX Hawaii PPO	$311.72

aztreonam 2 gm vial [KMC]

Facility

$321.36

Service Code	NDC 63323040230
Hospital Revenue Code	250
Min. Negotiated Rate	$134.97
Max. Negotiated Rate	$311.72
Rate for Payer: AlohaCare Medicaid	$160.68
Rate for Payer: AlohaCare Medicare	$134.97
Rate for Payer: Cash Price	$208.88
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$295.65
Rate for Payer: Devoted Health Medicare	$134.97
Rate for Payer: Hawaii Medical Service Association Medicare	$134.97
Rate for Payer: Hawaii Western Management Group Commercial	$305.29
Rate for Payer: Health Management Network Commercial	$273.16
Rate for Payer: Humana Medicare	$134.97
Rate for Payer: Kaiser Permanente Commercial	$289.22
Rate for Payer: Kaiser Permanente Medicaid	$163.89
Rate for Payer: Kaiser Permanente Medicare	$134.97
Rate for Payer: MDX Hawaii PPO	$311.72
Rate for Payer: Ohana Health Plan Medicaid	$134.97
Rate for Payer: Ohana Health Plan Medicare	$134.97
Rate for Payer: UnitedHealthcare Medicaid	$192.82
Rate for Payer: UnitedHealthcare Medicare	$134.97
Rate for Payer: University Health Alliance Commercial	$234.24

bacitracin 500 units/gm ointment packet [KMC]

Facility

$3.00

Service Code	NDC 00168011109
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

bacitracin 500 units/gm ointment packet [KMC]

Facility

$3.00

Service Code	NDC 00168011109
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

bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oint [KMC]

Facility

$1.02

Service Code	NDC 00472017956
Hospital Revenue Code	250
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.99
Rate for Payer: Cash Price	$0.66
Rate for Payer: Health Management Network Commercial	$0.87
Rate for Payer: Kaiser Permanente Commercial	$0.92
Rate for Payer: MDX Hawaii PPO	$0.99

Know your out-of-pocket cost for care.

All Charges