Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

budesonide-formoterol 160-4.5 mcg Inhaler [KMC]

Facility

$158.02

Service Code	NDC 00310737020
Hospital Revenue Code	250
Min. Negotiated Rate	$66.37
Max. Negotiated Rate	$153.28
Rate for Payer: AlohaCare Medicaid	$79.01
Rate for Payer: AlohaCare Medicare	$66.37
Rate for Payer: Cash Price	$102.71
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$145.38
Rate for Payer: Devoted Health Medicare	$66.37
Rate for Payer: Hawaii Medical Service Association Medicare	$66.37
Rate for Payer: Hawaii Western Management Group Commercial	$150.12
Rate for Payer: Health Management Network Commercial	$134.32
Rate for Payer: Humana Medicare	$66.37
Rate for Payer: Kaiser Permanente Commercial	$142.22
Rate for Payer: Kaiser Permanente Medicaid	$80.59
Rate for Payer: Kaiser Permanente Medicare	$66.37
Rate for Payer: MDX Hawaii PPO	$153.28
Rate for Payer: Ohana Health Plan Medicaid	$66.37
Rate for Payer: Ohana Health Plan Medicare	$66.37
Rate for Payer: UnitedHealthcare Medicaid	$94.81
Rate for Payer: UnitedHealthcare Medicare	$66.37
Rate for Payer: University Health Alliance Commercial	$115.18

budesonide-formoterol 80-4.5 mcg Inhaler [KMC]

Facility

$138.24

Service Code	NDC 00310737220
Hospital Revenue Code	250
Min. Negotiated Rate	$58.06
Max. Negotiated Rate	$134.09
Rate for Payer: AlohaCare Medicaid	$69.12
Rate for Payer: AlohaCare Medicare	$58.06
Rate for Payer: Cash Price	$89.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$127.18
Rate for Payer: Devoted Health Medicare	$58.06
Rate for Payer: Hawaii Medical Service Association Medicare	$58.06
Rate for Payer: Hawaii Western Management Group Commercial	$131.33
Rate for Payer: Health Management Network Commercial	$117.50
Rate for Payer: Humana Medicare	$58.06
Rate for Payer: Kaiser Permanente Commercial	$124.42
Rate for Payer: Kaiser Permanente Medicaid	$70.50
Rate for Payer: Kaiser Permanente Medicare	$58.06
Rate for Payer: MDX Hawaii PPO	$134.09
Rate for Payer: Ohana Health Plan Medicaid	$58.06
Rate for Payer: Ohana Health Plan Medicare	$58.06
Rate for Payer: UnitedHealthcare Medicaid	$82.94
Rate for Payer: UnitedHealthcare Medicare	$58.06
Rate for Payer: University Health Alliance Commercial	$100.76

budesonide-formoterol 80-4.5 mcg Inhaler [KMC]

Facility

$138.24

Service Code	NDC 00310737220
Hospital Revenue Code	250
Min. Negotiated Rate	$117.50
Max. Negotiated Rate	$134.09
Rate for Payer: Cash Price	$89.86
Rate for Payer: Health Management Network Commercial	$117.50
Rate for Payer: Kaiser Permanente Commercial	$124.42
Rate for Payer: MDX Hawaii PPO	$134.09

budesonide-formoterol-glycopyrrolate 160-4.8-9 mcg inhaler

Facility

$280.98

Service Code	NDC 00310461612
Hospital Revenue Code	250
Min. Negotiated Rate	$118.01
Max. Negotiated Rate	$272.55
Rate for Payer: AlohaCare Medicaid	$140.49
Rate for Payer: AlohaCare Medicare	$118.01
Rate for Payer: Cash Price	$182.64
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$258.50
Rate for Payer: Devoted Health Medicare	$118.01
Rate for Payer: Hawaii Medical Service Association Medicare	$118.01
Rate for Payer: Hawaii Western Management Group Commercial	$266.93
Rate for Payer: Health Management Network Commercial	$238.83
Rate for Payer: Humana Medicare	$118.01
Rate for Payer: Kaiser Permanente Commercial	$252.88
Rate for Payer: Kaiser Permanente Medicaid	$143.30
Rate for Payer: Kaiser Permanente Medicare	$118.01
Rate for Payer: MDX Hawaii PPO	$272.55
Rate for Payer: Ohana Health Plan Medicaid	$118.01
Rate for Payer: Ohana Health Plan Medicare	$118.01
Rate for Payer: UnitedHealthcare Medicaid	$168.59
Rate for Payer: UnitedHealthcare Medicare	$118.01
Rate for Payer: University Health Alliance Commercial	$204.81

budesonide-formoterol-glycopyrrolate 160-4.8-9 mcg inhaler

Facility

$280.98

Service Code	NDC 00310461612
Hospital Revenue Code	250
Min. Negotiated Rate	$238.83
Max. Negotiated Rate	$272.55
Rate for Payer: Cash Price	$182.64
Rate for Payer: Health Management Network Commercial	$238.83
Rate for Payer: Kaiser Permanente Commercial	$252.88
Rate for Payer: MDX Hawaii PPO	$272.55

bumetanide 1 mg Tab [KMC]

Facility

$10.68

Service Code	NDC 43547089710
Hospital Revenue Code	250
Min. Negotiated Rate	$9.08
Max. Negotiated Rate	$10.36
Rate for Payer: Cash Price	$6.94
Rate for Payer: Health Management Network Commercial	$9.08
Rate for Payer: Kaiser Permanente Commercial	$9.61
Rate for Payer: MDX Hawaii PPO	$10.36

bumetanide 1 mg Tab [KMC]

Facility

$10.68

Service Code	NDC 43547089710
Hospital Revenue Code	250
Min. Negotiated Rate	$4.49
Max. Negotiated Rate	$10.36
Rate for Payer: AlohaCare Medicaid	$5.34
Rate for Payer: AlohaCare Medicare	$4.49
Rate for Payer: Cash Price	$6.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.83
Rate for Payer: Devoted Health Medicare	$4.49
Rate for Payer: Hawaii Medical Service Association Medicare	$4.49
Rate for Payer: Hawaii Western Management Group Commercial	$10.15
Rate for Payer: Health Management Network Commercial	$9.08
Rate for Payer: Humana Medicare	$4.49
Rate for Payer: Kaiser Permanente Commercial	$9.61
Rate for Payer: Kaiser Permanente Medicaid	$5.45
Rate for Payer: Kaiser Permanente Medicare	$4.49
Rate for Payer: MDX Hawaii PPO	$10.36
Rate for Payer: Ohana Health Plan Medicaid	$4.49
Rate for Payer: Ohana Health Plan Medicare	$4.49
Rate for Payer: UnitedHealthcare Medicaid	$6.41
Rate for Payer: UnitedHealthcare Medicare	$4.49
Rate for Payer: University Health Alliance Commercial	$7.78

bumetanide 2.5 mg / 10 mL (0.25 mg/mL) Soln [KMC]

Facility

$1.57

Service Code	HCPCS S0171
Hospital Revenue Code	637
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.52
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Management Network Commercial	$1.33
Rate for Payer: Kaiser Permanente Commercial	$1.41
Rate for Payer: MDX Hawaii PPO	$1.52

bumetanide 2.5 mg / 10 mL (0.25 mg/mL) Soln [KMC]

Facility

$1.57

Service Code	HCPCS S0171
Hospital Revenue Code	637
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.52
Rate for Payer: AlohaCare Medicaid	$0.79
Rate for Payer: AlohaCare Medicare	$0.66
Rate for Payer: Cash Price	$1.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.44
Rate for Payer: Devoted Health Medicare	$0.66
Rate for Payer: Hawaii Medical Service Association Medicare	$0.66
Rate for Payer: Hawaii Western Management Group Commercial	$1.49
Rate for Payer: Health Management Network Commercial	$1.33
Rate for Payer: Humana Medicare	$0.66
Rate for Payer: Kaiser Permanente Commercial	$1.41
Rate for Payer: Kaiser Permanente Medicaid	$0.80
Rate for Payer: Kaiser Permanente Medicare	$0.66
Rate for Payer: MDX Hawaii PPO	$1.52
Rate for Payer: Ohana Health Plan Medicaid	$0.66
Rate for Payer: Ohana Health Plan Medicare	$0.66
Rate for Payer: UnitedHealthcare Medicare	$0.66
Rate for Payer: University Health Alliance Commercial	$1.14

bumetanide 2 mg Tab [KMC]

Facility

$11.84

Service Code	NDC 00832054211
Hospital Revenue Code	250
Min. Negotiated Rate	$10.06
Max. Negotiated Rate	$11.48
Rate for Payer: Cash Price	$7.70
Rate for Payer: Health Management Network Commercial	$10.06
Rate for Payer: Kaiser Permanente Commercial	$10.66
Rate for Payer: MDX Hawaii PPO	$11.48

bumetanide 2 mg Tab [KMC]

Facility

$11.84

Service Code	NDC 00832054211
Hospital Revenue Code	250
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$11.48
Rate for Payer: AlohaCare Medicaid	$5.92
Rate for Payer: AlohaCare Medicare	$4.97
Rate for Payer: Cash Price	$7.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.89
Rate for Payer: Devoted Health Medicare	$4.97
Rate for Payer: Hawaii Medical Service Association Medicare	$4.97
Rate for Payer: Hawaii Western Management Group Commercial	$11.25
Rate for Payer: Health Management Network Commercial	$10.06
Rate for Payer: Humana Medicare	$4.97
Rate for Payer: Kaiser Permanente Commercial	$10.66
Rate for Payer: Kaiser Permanente Medicaid	$6.04
Rate for Payer: Kaiser Permanente Medicare	$4.97
Rate for Payer: MDX Hawaii PPO	$11.48
Rate for Payer: Ohana Health Plan Medicaid	$4.97
Rate for Payer: Ohana Health Plan Medicare	$4.97
Rate for Payer: UnitedHealthcare Medicaid	$7.10
Rate for Payer: UnitedHealthcare Medicare	$4.97
Rate for Payer: University Health Alliance Commercial	$8.63

BUN

Facility

$72.00

Service Code	HCPCS 84520
Hospital Charge Code	422845200
Hospital Revenue Code	301
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

BUN

Facility

$72.00

Service Code	HCPCS 84520
Hospital Charge Code	422845200
Hospital Revenue Code	301
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$30.24
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$66.24
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$5.45
Rate for Payer: Hawaii Medical Service Association Commercial	$4.94
Rate for Payer: Hawaii Medical Service Association Medicare	$30.24
Rate for Payer: Hawaii Western Management Group Commercial	$3.95
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$30.24
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$30.24
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$30.24
Rate for Payer: Ohana Health Plan Medicare	$30.24
Rate for Payer: UnitedHealthcare Medicaid	$5.45
Rate for Payer: UnitedHealthcare Medicare	$30.24
Rate for Payer: University Health Alliance Commercial	$10.19

bupivacaine 0.5% Inj Soln [KMC]

Facility

$2.19

Service Code	HCPCS S0020
Hospital Revenue Code	637
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$2.12
Rate for Payer: AlohaCare Medicaid	$1.09
Rate for Payer: AlohaCare Medicare	$0.92
Rate for Payer: Cash Price	$1.42
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.01
Rate for Payer: Devoted Health Medicare	$0.92
Rate for Payer: Hawaii Medical Service Association Medicare	$0.92
Rate for Payer: Hawaii Western Management Group Commercial	$2.08
Rate for Payer: Health Management Network Commercial	$1.86
Rate for Payer: Humana Medicare	$0.92
Rate for Payer: Kaiser Permanente Commercial	$1.97
Rate for Payer: Kaiser Permanente Medicaid	$1.12
Rate for Payer: Kaiser Permanente Medicare	$0.92
Rate for Payer: MDX Hawaii PPO	$2.12
Rate for Payer: Ohana Health Plan Medicaid	$0.92
Rate for Payer: Ohana Health Plan Medicare	$0.92
Rate for Payer: UnitedHealthcare Medicare	$0.92
Rate for Payer: University Health Alliance Commercial	$1.60

bupivacaine 0.5% Inj Soln [KMC]

Facility

$2.19

Service Code	HCPCS S0020
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$2.12
Rate for Payer: Cash Price	$1.42
Rate for Payer: Health Management Network Commercial	$1.86
Rate for Payer: Kaiser Permanente Commercial	$1.97
Rate for Payer: MDX Hawaii PPO	$2.12

bupivacaine-epinephrine 0.5%-1:200k soln [KMC]

Facility

$0.86

Service Code	NDC 00409420810
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.83
Rate for Payer: AlohaCare Medicaid	$0.43
Rate for Payer: AlohaCare Medicare	$0.36
Rate for Payer: Cash Price	$0.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.79
Rate for Payer: Devoted Health Medicare	$0.36
Rate for Payer: Hawaii Medical Service Association Medicare	$0.36
Rate for Payer: Hawaii Western Management Group Commercial	$0.82
Rate for Payer: Health Management Network Commercial	$0.73
Rate for Payer: Humana Medicare	$0.36
Rate for Payer: Kaiser Permanente Commercial	$0.77
Rate for Payer: Kaiser Permanente Medicaid	$0.44
Rate for Payer: Kaiser Permanente Medicare	$0.36
Rate for Payer: MDX Hawaii PPO	$0.83
Rate for Payer: Ohana Health Plan Medicaid	$0.36
Rate for Payer: Ohana Health Plan Medicare	$0.36
Rate for Payer: UnitedHealthcare Medicaid	$0.52
Rate for Payer: UnitedHealthcare Medicare	$0.36
Rate for Payer: University Health Alliance Commercial	$0.63

bupivacaine-epinephrine 0.5%-1:200k soln [KMC]

Facility

$0.86

Service Code	NDC 00409420810
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.83
Rate for Payer: Cash Price	$0.56
Rate for Payer: Health Management Network Commercial	$0.73
Rate for Payer: Kaiser Permanente Commercial	$0.77
Rate for Payer: MDX Hawaii PPO	$0.83

buprenorphine 2 mg SL Tab [KMC]

Facility

$3.00

Service Code	HCPCS J0571
Hospital Revenue Code	636
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

buprenorphine 2 mg SL Tab [KMC]

Facility

$3.00

Service Code	HCPCS J0571
Hospital Revenue Code	636
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

buprenorphine 5 mcg/hr ER patch [KMC]

Facility

$245.46

Service Code	NDC 59011075004
Hospital Revenue Code	250
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$238.10
Rate for Payer: AlohaCare Medicaid	$122.73
Rate for Payer: AlohaCare Medicare	$103.09
Rate for Payer: Cash Price	$159.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$225.82
Rate for Payer: Devoted Health Medicare	$103.09
Rate for Payer: Hawaii Medical Service Association Medicare	$103.09
Rate for Payer: Hawaii Western Management Group Commercial	$233.19
Rate for Payer: Health Management Network Commercial	$208.64
Rate for Payer: Humana Medicare	$103.09
Rate for Payer: Kaiser Permanente Commercial	$220.91
Rate for Payer: Kaiser Permanente Medicaid	$125.18
Rate for Payer: Kaiser Permanente Medicare	$103.09
Rate for Payer: MDX Hawaii PPO	$238.10
Rate for Payer: Ohana Health Plan Medicaid	$103.09
Rate for Payer: Ohana Health Plan Medicare	$103.09
Rate for Payer: UnitedHealthcare Medicaid	$147.28
Rate for Payer: UnitedHealthcare Medicare	$103.09
Rate for Payer: University Health Alliance Commercial	$178.92

buprenorphine 5 mcg/hr ER patch [KMC]

Facility

$245.46

Service Code	NDC 59011075004
Hospital Revenue Code	250
Min. Negotiated Rate	$208.64
Max. Negotiated Rate	$238.10
Rate for Payer: Cash Price	$159.55
Rate for Payer: Health Management Network Commercial	$208.64
Rate for Payer: Kaiser Permanente Commercial	$220.91
Rate for Payer: MDX Hawaii PPO	$238.10

buprenorphine 8 mg Tab [KMC]

Facility

$33.93

Service Code	HCPCS J0571
Hospital Revenue Code	636
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$32.91
Rate for Payer: AlohaCare Medicaid	$16.96
Rate for Payer: AlohaCare Medicare	$14.25
Rate for Payer: Cash Price	$22.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.22
Rate for Payer: Devoted Health Medicare	$14.25
Rate for Payer: Hawaii Medical Service Association Medicare	$14.25
Rate for Payer: Hawaii Western Management Group Commercial	$32.23
Rate for Payer: Health Management Network Commercial	$28.84
Rate for Payer: Humana Medicare	$14.25
Rate for Payer: Kaiser Permanente Commercial	$30.54
Rate for Payer: Kaiser Permanente Medicaid	$17.30
Rate for Payer: Kaiser Permanente Medicare	$14.25
Rate for Payer: MDX Hawaii PPO	$32.91
Rate for Payer: Ohana Health Plan Medicaid	$14.25
Rate for Payer: Ohana Health Plan Medicare	$14.25
Rate for Payer: UnitedHealthcare Medicaid	$20.36
Rate for Payer: UnitedHealthcare Medicare	$14.25
Rate for Payer: University Health Alliance Commercial	$24.73

buprenorphine 8 mg Tab [KMC]

Facility

$33.93

Service Code	HCPCS J0571
Hospital Revenue Code	636
Min. Negotiated Rate	$28.84
Max. Negotiated Rate	$32.91
Rate for Payer: Cash Price	$22.05
Rate for Payer: Health Management Network Commercial	$28.84
Rate for Payer: Kaiser Permanente Commercial	$30.54
Rate for Payer: MDX Hawaii PPO	$32.91

buprenorphine-naloxone 2-0.5 mg Film [KMC]

Facility

$19.63

Service Code	HCPCS J0572
Hospital Revenue Code	636
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$19.04
Rate for Payer: AlohaCare Medicaid	$9.81
Rate for Payer: AlohaCare Medicare	$8.24
Rate for Payer: Cash Price	$12.76
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$18.06
Rate for Payer: Devoted Health Medicare	$8.24
Rate for Payer: Hawaii Medical Service Association Medicare	$8.24
Rate for Payer: Hawaii Western Management Group Commercial	$18.65
Rate for Payer: Health Management Network Commercial	$16.69
Rate for Payer: Humana Medicare	$8.24
Rate for Payer: Kaiser Permanente Commercial	$17.67
Rate for Payer: Kaiser Permanente Medicaid	$10.01
Rate for Payer: Kaiser Permanente Medicare	$8.24
Rate for Payer: MDX Hawaii PPO	$19.04
Rate for Payer: Ohana Health Plan Medicaid	$8.24
Rate for Payer: Ohana Health Plan Medicare	$8.24
Rate for Payer: UnitedHealthcare Medicaid	$11.78
Rate for Payer: UnitedHealthcare Medicare	$8.24
Rate for Payer: University Health Alliance Commercial	$14.31

buprenorphine-naloxone 2-0.5 mg Film [KMC]

Facility

$19.63

Service Code	HCPCS J0572
Hospital Revenue Code	636
Min. Negotiated Rate	$16.69
Max. Negotiated Rate	$19.04
Rate for Payer: Cash Price	$12.76
Rate for Payer: Health Management Network Commercial	$16.69
Rate for Payer: Kaiser Permanente Commercial	$17.67
Rate for Payer: MDX Hawaii PPO	$19.04

Know your out-of-pocket cost for care.

All Charges