Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

brimonidine-timolol ophthalmic 0.2%-0.5% Sol [KMC]

Facility

$177.30

Service Code	NDC 82182045505
Hospital Revenue Code	250
Min. Negotiated Rate	$150.71
Max. Negotiated Rate	$171.98
Rate for Payer: Cash Price	$115.24
Rate for Payer: Health Management Network Commercial	$150.71
Rate for Payer: Kaiser Permanente Commercial	$159.57
Rate for Payer: MDX Hawaii PPO	$171.98

brinzolamide ophthalmic 1% Drops [KMC]

Facility

$68.40

Service Code	NDC 00065027510
Hospital Revenue Code	250
Min. Negotiated Rate	$58.14
Max. Negotiated Rate	$66.35
Rate for Payer: Cash Price	$44.46
Rate for Payer: Health Management Network Commercial	$58.14
Rate for Payer: Kaiser Permanente Commercial	$61.56
Rate for Payer: MDX Hawaii PPO	$66.35

brinzolamide ophthalmic 1% Drops [KMC]

Facility

$68.40

Service Code	NDC 00065027510
Hospital Revenue Code	250
Min. Negotiated Rate	$28.73
Max. Negotiated Rate	$66.35
Rate for Payer: AlohaCare Medicaid	$34.20
Rate for Payer: AlohaCare Medicare	$28.73
Rate for Payer: Cash Price	$44.46
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$62.93
Rate for Payer: Devoted Health Medicare	$28.73
Rate for Payer: Hawaii Medical Service Association Medicare	$28.73
Rate for Payer: Hawaii Western Management Group Commercial	$64.98
Rate for Payer: Health Management Network Commercial	$58.14
Rate for Payer: Humana Medicare	$28.73
Rate for Payer: Kaiser Permanente Commercial	$61.56
Rate for Payer: Kaiser Permanente Medicaid	$34.88
Rate for Payer: Kaiser Permanente Medicare	$28.73
Rate for Payer: MDX Hawaii PPO	$66.35
Rate for Payer: Ohana Health Plan Medicaid	$28.73
Rate for Payer: Ohana Health Plan Medicare	$28.73
Rate for Payer: UnitedHealthcare Medicaid	$41.04
Rate for Payer: UnitedHealthcare Medicare	$28.73
Rate for Payer: University Health Alliance Commercial	$49.86

brivaracetam 100 mg Tab [KMC]

Facility

$120.90

Service Code	NDC 50474077066
Hospital Revenue Code	250
Min. Negotiated Rate	$50.78
Max. Negotiated Rate	$117.27
Rate for Payer: AlohaCare Medicaid	$60.45
Rate for Payer: AlohaCare Medicare	$50.78
Rate for Payer: Cash Price	$78.59
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$111.23
Rate for Payer: Devoted Health Medicare	$50.78
Rate for Payer: Hawaii Medical Service Association Medicare	$50.78
Rate for Payer: Hawaii Western Management Group Commercial	$114.86
Rate for Payer: Health Management Network Commercial	$102.77
Rate for Payer: Humana Medicare	$50.78
Rate for Payer: Kaiser Permanente Commercial	$108.81
Rate for Payer: Kaiser Permanente Medicaid	$61.66
Rate for Payer: Kaiser Permanente Medicare	$50.78
Rate for Payer: MDX Hawaii PPO	$117.27
Rate for Payer: Ohana Health Plan Medicaid	$50.78
Rate for Payer: Ohana Health Plan Medicare	$50.78
Rate for Payer: UnitedHealthcare Medicaid	$72.54
Rate for Payer: UnitedHealthcare Medicare	$50.78
Rate for Payer: University Health Alliance Commercial	$88.12

brivaracetam 100 mg Tab [KMC]

Facility

$120.90

Service Code	NDC 50474077066
Hospital Revenue Code	250
Min. Negotiated Rate	$102.77
Max. Negotiated Rate	$117.27
Rate for Payer: Cash Price	$78.59
Rate for Payer: Health Management Network Commercial	$102.77
Rate for Payer: Kaiser Permanente Commercial	$108.81
Rate for Payer: MDX Hawaii PPO	$117.27

brivaracetam 50 mg Tab

Facility

$120.90

Service Code	NDC 50474057066
Hospital Revenue Code	250
Min. Negotiated Rate	$50.78
Max. Negotiated Rate	$117.27
Rate for Payer: AlohaCare Medicaid	$60.45
Rate for Payer: AlohaCare Medicare	$50.78
Rate for Payer: Cash Price	$78.59
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$111.23
Rate for Payer: Devoted Health Medicare	$50.78
Rate for Payer: Hawaii Medical Service Association Medicare	$50.78
Rate for Payer: Hawaii Western Management Group Commercial	$114.86
Rate for Payer: Health Management Network Commercial	$102.77
Rate for Payer: Humana Medicare	$50.78
Rate for Payer: Kaiser Permanente Commercial	$108.81
Rate for Payer: Kaiser Permanente Medicaid	$61.66
Rate for Payer: Kaiser Permanente Medicare	$50.78
Rate for Payer: MDX Hawaii PPO	$117.27
Rate for Payer: Ohana Health Plan Medicaid	$50.78
Rate for Payer: Ohana Health Plan Medicare	$50.78
Rate for Payer: UnitedHealthcare Medicaid	$72.54
Rate for Payer: UnitedHealthcare Medicare	$50.78
Rate for Payer: University Health Alliance Commercial	$88.12

brivaracetam 50 mg Tab

Facility

$120.90

Service Code	NDC 50474057066
Hospital Revenue Code	250
Min. Negotiated Rate	$102.77
Max. Negotiated Rate	$117.27
Rate for Payer: Cash Price	$78.59
Rate for Payer: Health Management Network Commercial	$102.77
Rate for Payer: Kaiser Permanente Commercial	$108.81
Rate for Payer: MDX Hawaii PPO	$117.27

BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN

Professional

Both

$206.00

Service Code	HCPCS 94060
Hospital Revenue Code	410
Min. Negotiated Rate	$43.27
Max. Negotiated Rate	$175.10
Rate for Payer: AlohaCare Medicaid	$43.27
Rate for Payer: AlohaCare Medicare	$48.04
Rate for Payer: Cash Price	$133.90
Rate for Payer: Cash Price	$133.90
Rate for Payer: Devoted Health Medicare	$48.04
Rate for Payer: Hawaii Medical Service Association Medicare	$48.04
Rate for Payer: Hawaii Western Management Group Commercial	$62.42
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Kaiser Permanente Commercial	$57.65
Rate for Payer: Kaiser Permanente Medicaid	$57.65
Rate for Payer: Kaiser Permanente Medicare	$57.65
Rate for Payer: Ohana Health Plan Medicaid	$43.27
Rate for Payer: Ohana Health Plan Medicare	$48.04
Rate for Payer: UnitedHealthcare Medicaid	$43.27
Rate for Payer: UnitedHealthcare Medicare	$48.04

bromfenac ophthalmic 0.07% Soln [KMC]

Facility

$452.27

Service Code	NDC 24208060203
Hospital Revenue Code	250
Min. Negotiated Rate	$189.95
Max. Negotiated Rate	$438.70
Rate for Payer: AlohaCare Medicaid	$226.13
Rate for Payer: AlohaCare Medicare	$189.95
Rate for Payer: Cash Price	$293.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$416.09
Rate for Payer: Devoted Health Medicare	$189.95
Rate for Payer: Hawaii Medical Service Association Medicare	$189.95
Rate for Payer: Hawaii Western Management Group Commercial	$429.66
Rate for Payer: Health Management Network Commercial	$384.43
Rate for Payer: Humana Medicare	$189.95
Rate for Payer: Kaiser Permanente Commercial	$407.04
Rate for Payer: Kaiser Permanente Medicaid	$230.66
Rate for Payer: Kaiser Permanente Medicare	$189.95
Rate for Payer: MDX Hawaii PPO	$438.70
Rate for Payer: Ohana Health Plan Medicaid	$189.95
Rate for Payer: Ohana Health Plan Medicare	$189.95
Rate for Payer: UnitedHealthcare Medicaid	$271.36
Rate for Payer: UnitedHealthcare Medicare	$189.95
Rate for Payer: University Health Alliance Commercial	$329.66

bromfenac ophthalmic 0.07% Soln [KMC]

Facility

$452.27

Service Code	NDC 24208060203
Hospital Revenue Code	250
Min. Negotiated Rate	$384.43
Max. Negotiated Rate	$438.70
Rate for Payer: Cash Price	$293.98
Rate for Payer: Health Management Network Commercial	$384.43
Rate for Payer: Kaiser Permanente Commercial	$407.04
Rate for Payer: MDX Hawaii PPO	$438.70

BRONCHITIS AND ASTHMA WITH CC/MCC

Facility

$17,800.20

Service Code	MSDRG 202
Min. Negotiated Rate	$17,800.20
Max. Negotiated Rate	$17,800.20
Rate for Payer: Hawaii Medical Service Association Commercial	$17,800.20

BRONCHITIS AND ASTHMA WITHOUT CC/MCC

Facility

$13,533.84

Service Code	MSDRG 203
Min. Negotiated Rate	$13,533.84
Max. Negotiated Rate	$13,533.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13,533.84

Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010 with administer

Facility

$662.00

Service Code	HCPCS 95070
Hospital Charge Code	429950700
Hospital Revenue Code	410
Min. Negotiated Rate	$73.17
Max. Negotiated Rate	$642.14
Rate for Payer: AlohaCare Medicaid	$331.00
Rate for Payer: AlohaCare Medicare	$278.04
Rate for Payer: Cash Price	$430.30
Rate for Payer: Cash Price	$430.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$609.04
Rate for Payer: Devoted Health Medicare	$278.04
Rate for Payer: Hawaii Medical Service Association Commercial	$551.04
Rate for Payer: Hawaii Medical Service Association Medicare	$278.04
Rate for Payer: Hawaii Western Management Group Commercial	$628.90
Rate for Payer: Health Management Network Commercial	$562.70
Rate for Payer: Humana Medicare	$278.04
Rate for Payer: Kaiser Permanente Commercial	$595.80
Rate for Payer: Kaiser Permanente Medicaid	$337.62
Rate for Payer: Kaiser Permanente Medicare	$278.04
Rate for Payer: MDX Hawaii PPO	$642.14
Rate for Payer: Ohana Health Plan Medicaid	$278.04
Rate for Payer: Ohana Health Plan Medicare	$278.04
Rate for Payer: UnitedHealthcare Medicaid	$73.17
Rate for Payer: UnitedHealthcare Medicare	$278.04
Rate for Payer: University Health Alliance Commercial	$482.53

Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010 with administer

Facility

$662.00

Service Code	HCPCS 95070
Hospital Charge Code	429950700
Hospital Revenue Code	410
Min. Negotiated Rate	$562.70
Max. Negotiated Rate	$642.14
Rate for Payer: Cash Price	$430.30
Rate for Payer: Health Management Network Commercial	$562.70
Rate for Payer: Kaiser Permanente Commercial	$595.80
Rate for Payer: MDX Hawaii PPO	$642.14

BRONCHOSPSM PRE/POST EVAL Respiratory Therapy Charges

Facility

$471.00

Service Code	HCPCS 94060
Hospital Charge Code	429940600
Hospital Revenue Code	460
Min. Negotiated Rate	$400.35
Max. Negotiated Rate	$456.87
Rate for Payer: Cash Price	$306.15
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: Kaiser Permanente Commercial	$423.90
Rate for Payer: MDX Hawaii PPO	$456.87

BRONCHOSPSM PRE/POST EVAL Respiratory Therapy Charges

Facility

$471.00

Service Code	HCPCS 94060
Hospital Charge Code	429940600
Hospital Revenue Code	460
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$551.04
Rate for Payer: AlohaCare Medicaid	$235.50
Rate for Payer: AlohaCare Medicare	$197.82
Rate for Payer: Cash Price	$306.15
Rate for Payer: Cash Price	$306.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$433.32
Rate for Payer: Devoted Health Medicare	$197.82
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$31.20
Rate for Payer: Hawaii Medical Service Association Commercial	$551.04
Rate for Payer: Hawaii Medical Service Association Medicare	$197.82
Rate for Payer: Hawaii Western Management Group Commercial	$447.45
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: Humana Medicare	$197.82
Rate for Payer: Kaiser Permanente Commercial	$423.90
Rate for Payer: Kaiser Permanente Medicaid	$240.21
Rate for Payer: Kaiser Permanente Medicare	$197.82
Rate for Payer: MDX Hawaii PPO	$456.87
Rate for Payer: Ohana Health Plan Medicaid	$197.82
Rate for Payer: Ohana Health Plan Medicare	$197.82
Rate for Payer: UnitedHealthcare Medicaid	$31.20
Rate for Payer: UnitedHealthcare Medicare	$197.82
Rate for Payer: University Health Alliance Commercial	$343.31

budesonide 0.5 mg/2 mL Inh Susp [KMC]

Facility

$22.16

Service Code	HCPCS J7626
Hospital Revenue Code	636
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$21.50
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$18.84
Rate for Payer: Kaiser Permanente Commercial	$19.94
Rate for Payer: MDX Hawaii PPO	$21.50

budesonide 0.5 mg/2 mL Inh Susp [KMC]

Facility

$22.16

Service Code	HCPCS J7626
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$21.50
Rate for Payer: AlohaCare Medicaid	$11.08
Rate for Payer: AlohaCare Medicare	$9.31
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cash Price	$14.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$20.39
Rate for Payer: Devoted Health Medicare	$9.31
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.28
Rate for Payer: Hawaii Medical Service Association Medicare	$9.31
Rate for Payer: Hawaii Western Management Group Commercial	$21.05
Rate for Payer: Health Management Network Commercial	$18.84
Rate for Payer: Humana Medicare	$9.31
Rate for Payer: Kaiser Permanente Commercial	$19.94
Rate for Payer: Kaiser Permanente Medicaid	$11.30
Rate for Payer: Kaiser Permanente Medicare	$9.31
Rate for Payer: MDX Hawaii PPO	$21.50
Rate for Payer: Ohana Health Plan Medicaid	$9.31
Rate for Payer: Ohana Health Plan Medicare	$9.31
Rate for Payer: UnitedHealthcare Medicaid	$13.30
Rate for Payer: UnitedHealthcare Medicare	$9.31
Rate for Payer: University Health Alliance Commercial	$16.15

budesonide 180 mcg/puff inhaler [KMC]

Facility

$1,134.64

Service Code	NDC 00186091612
Hospital Revenue Code	250
Min. Negotiated Rate	$964.44
Max. Negotiated Rate	$1,100.60
Rate for Payer: Cash Price	$737.52
Rate for Payer: Health Management Network Commercial	$964.44
Rate for Payer: Kaiser Permanente Commercial	$1,021.18
Rate for Payer: MDX Hawaii PPO	$1,100.60

budesonide 180 mcg/puff inhaler [KMC]

Facility

$1,134.64

Service Code	NDC 00186091612
Hospital Revenue Code	250
Min. Negotiated Rate	$476.55
Max. Negotiated Rate	$1,100.60
Rate for Payer: AlohaCare Medicaid	$567.32
Rate for Payer: AlohaCare Medicare	$476.55
Rate for Payer: Cash Price	$737.52
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,043.87
Rate for Payer: Devoted Health Medicare	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$476.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,077.91
Rate for Payer: Health Management Network Commercial	$964.44
Rate for Payer: Humana Medicare	$476.55
Rate for Payer: Kaiser Permanente Commercial	$1,021.18
Rate for Payer: Kaiser Permanente Medicaid	$578.67
Rate for Payer: Kaiser Permanente Medicare	$476.55
Rate for Payer: MDX Hawaii PPO	$1,100.60
Rate for Payer: Ohana Health Plan Medicaid	$476.55
Rate for Payer: Ohana Health Plan Medicare	$476.55
Rate for Payer: UnitedHealthcare Medicaid	$680.78
Rate for Payer: UnitedHealthcare Medicare	$476.55
Rate for Payer: University Health Alliance Commercial	$827.04

budesonide 1 mg/2 mL Neb [KMC]

Facility

$25.00

Service Code	HCPCS J7626
Hospital Revenue Code	636
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$24.25
Rate for Payer: AlohaCare Medicaid	$12.50
Rate for Payer: AlohaCare Medicare	$10.50
Rate for Payer: Cash Price	$16.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$23.00
Rate for Payer: Devoted Health Medicare	$10.50
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.28
Rate for Payer: Hawaii Medical Service Association Medicare	$10.50
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Humana Medicare	$10.50
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicare	$10.50
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: Ohana Health Plan Medicaid	$10.50
Rate for Payer: Ohana Health Plan Medicare	$10.50
Rate for Payer: UnitedHealthcare Medicaid	$15.00
Rate for Payer: UnitedHealthcare Medicare	$10.50
Rate for Payer: University Health Alliance Commercial	$18.22

budesonide 1 mg/2 mL Neb [KMC]

Facility

$25.00

Service Code	HCPCS J7626
Hospital Revenue Code	636
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$16.25
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Kaiser Permanente Commercial	$22.50
Rate for Payer: MDX Hawaii PPO	$24.25

budesonide 9 mg ER Tab [KMC]

Facility

$257.88

Service Code	NDC 68682030930
Hospital Revenue Code	250
Min. Negotiated Rate	$219.20
Max. Negotiated Rate	$250.14
Rate for Payer: Cash Price	$167.62
Rate for Payer: Health Management Network Commercial	$219.20
Rate for Payer: Kaiser Permanente Commercial	$232.09
Rate for Payer: MDX Hawaii PPO	$250.14

budesonide 9 mg ER Tab [KMC]

Facility

$257.88

Service Code	NDC 68682030930
Hospital Revenue Code	250
Min. Negotiated Rate	$108.31
Max. Negotiated Rate	$250.14
Rate for Payer: AlohaCare Medicaid	$128.94
Rate for Payer: AlohaCare Medicare	$108.31
Rate for Payer: Cash Price	$167.62
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$237.25
Rate for Payer: Devoted Health Medicare	$108.31
Rate for Payer: Hawaii Medical Service Association Medicare	$108.31
Rate for Payer: Hawaii Western Management Group Commercial	$244.99
Rate for Payer: Health Management Network Commercial	$219.20
Rate for Payer: Humana Medicare	$108.31
Rate for Payer: Kaiser Permanente Commercial	$232.09
Rate for Payer: Kaiser Permanente Medicaid	$131.52
Rate for Payer: Kaiser Permanente Medicare	$108.31
Rate for Payer: MDX Hawaii PPO	$250.14
Rate for Payer: Ohana Health Plan Medicaid	$108.31
Rate for Payer: Ohana Health Plan Medicare	$108.31
Rate for Payer: UnitedHealthcare Medicaid	$154.73
Rate for Payer: UnitedHealthcare Medicare	$108.31
Rate for Payer: University Health Alliance Commercial	$187.97

budesonide-formoterol 160-4.5 mcg Inhaler [KMC]

Facility

$158.02

Service Code	NDC 00310737020
Hospital Revenue Code	250
Min. Negotiated Rate	$134.32
Max. Negotiated Rate	$153.28
Rate for Payer: Cash Price	$102.71
Rate for Payer: Health Management Network Commercial	$134.32
Rate for Payer: Kaiser Permanente Commercial	$142.22
Rate for Payer: MDX Hawaii PPO	$153.28

Know your out-of-pocket cost for care.

All Charges