Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

buprenorphine-naloxone 2-0.5 mg Tab [KMC]

Facility

$23.30

Service Code	HCPCS J0572
Hospital Revenue Code	636
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$22.60
Rate for Payer: Cash Price	$15.15
Rate for Payer: Health Management Network Commercial	$19.80
Rate for Payer: Kaiser Permanente Commercial	$20.97
Rate for Payer: MDX Hawaii PPO	$22.60

buprenorphine-naloxone 2-0.5 mg Tab [KMC]

Facility

$23.30

Service Code	HCPCS J0572
Hospital Revenue Code	636
Min. Negotiated Rate	$9.79
Max. Negotiated Rate	$22.60
Rate for Payer: AlohaCare Medicaid	$11.65
Rate for Payer: AlohaCare Medicare	$9.79
Rate for Payer: Cash Price	$15.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.44
Rate for Payer: Devoted Health Medicare	$9.79
Rate for Payer: Hawaii Medical Service Association Medicare	$9.79
Rate for Payer: Hawaii Western Management Group Commercial	$22.14
Rate for Payer: Health Management Network Commercial	$19.80
Rate for Payer: Humana Medicare	$9.79
Rate for Payer: Kaiser Permanente Commercial	$20.97
Rate for Payer: Kaiser Permanente Medicaid	$11.88
Rate for Payer: Kaiser Permanente Medicare	$9.79
Rate for Payer: MDX Hawaii PPO	$22.60
Rate for Payer: Ohana Health Plan Medicaid	$9.79
Rate for Payer: Ohana Health Plan Medicare	$9.79
Rate for Payer: UnitedHealthcare Medicaid	$13.98
Rate for Payer: UnitedHealthcare Medicare	$9.79
Rate for Payer: University Health Alliance Commercial	$16.98

buprenorphine-naloxone 8-2 mg Film [KMC]

Facility

$35.16

Service Code	HCPCS J0574
Hospital Revenue Code	636
Min. Negotiated Rate	$14.77
Max. Negotiated Rate	$34.11
Rate for Payer: AlohaCare Medicaid	$17.58
Rate for Payer: AlohaCare Medicare	$14.77
Rate for Payer: Cash Price	$22.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$32.35
Rate for Payer: Devoted Health Medicare	$14.77
Rate for Payer: Hawaii Medical Service Association Medicare	$14.77
Rate for Payer: Hawaii Western Management Group Commercial	$33.40
Rate for Payer: Health Management Network Commercial	$29.89
Rate for Payer: Humana Medicare	$14.77
Rate for Payer: Kaiser Permanente Commercial	$31.64
Rate for Payer: Kaiser Permanente Medicaid	$17.93
Rate for Payer: Kaiser Permanente Medicare	$14.77
Rate for Payer: MDX Hawaii PPO	$34.11
Rate for Payer: Ohana Health Plan Medicaid	$14.77
Rate for Payer: Ohana Health Plan Medicare	$14.77
Rate for Payer: UnitedHealthcare Medicaid	$21.10
Rate for Payer: UnitedHealthcare Medicare	$14.77
Rate for Payer: University Health Alliance Commercial	$25.63

buprenorphine-naloxone 8-2 mg Film [KMC]

Facility

$35.16

Service Code	HCPCS J0574
Hospital Revenue Code	636
Min. Negotiated Rate	$29.89
Max. Negotiated Rate	$34.11
Rate for Payer: Cash Price	$22.85
Rate for Payer: Health Management Network Commercial	$29.89
Rate for Payer: Kaiser Permanente Commercial	$31.64
Rate for Payer: MDX Hawaii PPO	$34.11

buPROPion 100 mg (12hr) SR Tab [KMC]

Facility

$3.00

Service Code	NDC 42806041001
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

buPROPion 100 mg (12hr) SR Tab [KMC]

Facility

$3.00

Service Code	NDC 42806041001
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

buPROPion 100 mg Tab [KMC]

Facility

$4.24

Service Code	HCPCS J0878
Hospital Revenue Code	636
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$4.11
Rate for Payer: AlohaCare Medicaid	$2.12
Rate for Payer: AlohaCare Medicare	$1.78
Rate for Payer: Cash Price	$2.76
Rate for Payer: Cash Price	$2.76
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.90
Rate for Payer: Devoted Health Medicare	$1.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.91
Rate for Payer: Hawaii Medical Service Association Medicare	$1.78
Rate for Payer: Hawaii Western Management Group Commercial	$4.03
Rate for Payer: Health Management Network Commercial	$3.60
Rate for Payer: Humana Medicare	$1.78
Rate for Payer: Kaiser Permanente Commercial	$3.82
Rate for Payer: Kaiser Permanente Medicaid	$2.16
Rate for Payer: Kaiser Permanente Medicare	$1.78
Rate for Payer: MDX Hawaii PPO	$4.11
Rate for Payer: Ohana Health Plan Medicaid	$1.78
Rate for Payer: Ohana Health Plan Medicare	$1.78
Rate for Payer: UnitedHealthcare Medicaid	$2.54
Rate for Payer: UnitedHealthcare Medicare	$1.78
Rate for Payer: University Health Alliance Commercial	$3.09

buPROPion 100 mg Tab [KMC]

Facility

$4.24

Service Code	HCPCS J0878
Hospital Revenue Code	636
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$4.11
Rate for Payer: Cash Price	$2.76
Rate for Payer: Health Management Network Commercial	$3.60
Rate for Payer: Kaiser Permanente Commercial	$3.82
Rate for Payer: MDX Hawaii PPO	$4.11

buPROPion 150 mg XL tab (24-hour) [KMC]

Facility

$19.09

Service Code	NDC 68180031909
Hospital Revenue Code	250
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$18.52
Rate for Payer: AlohaCare Medicaid	$9.54
Rate for Payer: AlohaCare Medicare	$8.02
Rate for Payer: Cash Price	$12.41
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$17.56
Rate for Payer: Devoted Health Medicare	$8.02
Rate for Payer: Hawaii Medical Service Association Medicare	$8.02
Rate for Payer: Hawaii Western Management Group Commercial	$18.14
Rate for Payer: Health Management Network Commercial	$16.23
Rate for Payer: Humana Medicare	$8.02
Rate for Payer: Kaiser Permanente Commercial	$17.18
Rate for Payer: Kaiser Permanente Medicaid	$9.74
Rate for Payer: Kaiser Permanente Medicare	$8.02
Rate for Payer: MDX Hawaii PPO	$18.52
Rate for Payer: Ohana Health Plan Medicaid	$8.02
Rate for Payer: Ohana Health Plan Medicare	$8.02
Rate for Payer: UnitedHealthcare Medicaid	$11.45
Rate for Payer: UnitedHealthcare Medicare	$8.02
Rate for Payer: University Health Alliance Commercial	$13.91

buPROPion 150 mg XL tab (24-hour) [KMC]

Facility

$19.09

Service Code	NDC 68180031909
Hospital Revenue Code	250
Min. Negotiated Rate	$16.23
Max. Negotiated Rate	$18.52
Rate for Payer: Cash Price	$12.41
Rate for Payer: Health Management Network Commercial	$16.23
Rate for Payer: Kaiser Permanente Commercial	$17.18
Rate for Payer: MDX Hawaii PPO	$18.52

buPROPion 75 mg Tab [KMC]

Facility

$3.17

Service Code	NDC 24689011901
Hospital Revenue Code	250
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$3.07
Rate for Payer: AlohaCare Medicaid	$1.58
Rate for Payer: AlohaCare Medicare	$1.33
Rate for Payer: Cash Price	$2.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.92
Rate for Payer: Devoted Health Medicare	$1.33
Rate for Payer: Hawaii Medical Service Association Medicare	$1.33
Rate for Payer: Hawaii Western Management Group Commercial	$3.01
Rate for Payer: Health Management Network Commercial	$2.69
Rate for Payer: Humana Medicare	$1.33
Rate for Payer: Kaiser Permanente Commercial	$2.85
Rate for Payer: Kaiser Permanente Medicaid	$1.62
Rate for Payer: Kaiser Permanente Medicare	$1.33
Rate for Payer: MDX Hawaii PPO	$3.07
Rate for Payer: Ohana Health Plan Medicaid	$1.33
Rate for Payer: Ohana Health Plan Medicare	$1.33
Rate for Payer: UnitedHealthcare Medicaid	$1.90
Rate for Payer: UnitedHealthcare Medicare	$1.33
Rate for Payer: University Health Alliance Commercial	$2.31

buPROPion 75 mg Tab [KMC]

Facility

$3.17

Service Code	NDC 24689011901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$3.07
Rate for Payer: Cash Price	$2.06
Rate for Payer: Health Management Network Commercial	$2.69
Rate for Payer: Kaiser Permanente Commercial	$2.85
Rate for Payer: MDX Hawaii PPO	$3.07

BURETROL SOLUTION SET

Facility

$2.00

Hospital Charge Code	8046
Hospital Revenue Code	272
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

BURETROL SOLUTION SET

Facility

$2.00

Hospital Charge Code	8046
Hospital Revenue Code	272
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

busPIRone 15 mg Tab [KMC]

Facility

$8.08

Service Code	NDC 29300047701
Hospital Revenue Code	250
Min. Negotiated Rate	$6.87
Max. Negotiated Rate	$7.84
Rate for Payer: Cash Price	$5.25
Rate for Payer: Health Management Network Commercial	$6.87
Rate for Payer: Kaiser Permanente Commercial	$7.27
Rate for Payer: MDX Hawaii PPO	$7.84

busPIRone 15 mg Tab [KMC]

Facility

$8.08

Service Code	NDC 29300047701
Hospital Revenue Code	250
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$7.84
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$3.39
Rate for Payer: Cash Price	$5.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.43
Rate for Payer: Devoted Health Medicare	$3.39
Rate for Payer: Hawaii Medical Service Association Medicare	$3.39
Rate for Payer: Hawaii Western Management Group Commercial	$7.68
Rate for Payer: Health Management Network Commercial	$6.87
Rate for Payer: Humana Medicare	$3.39
Rate for Payer: Kaiser Permanente Commercial	$7.27
Rate for Payer: Kaiser Permanente Medicaid	$4.12
Rate for Payer: Kaiser Permanente Medicare	$3.39
Rate for Payer: MDX Hawaii PPO	$7.84
Rate for Payer: Ohana Health Plan Medicaid	$3.39
Rate for Payer: Ohana Health Plan Medicare	$3.39
Rate for Payer: UnitedHealthcare Medicaid	$4.85
Rate for Payer: UnitedHealthcare Medicare	$3.39
Rate for Payer: University Health Alliance Commercial	$5.89

butalbital-APAP-caffeine 50-325-40 mg Tab [KMC]

Facility

$6.75

Service Code	NDC 69367020301
Hospital Revenue Code	250
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$6.55
Rate for Payer: Cash Price	$4.39
Rate for Payer: Health Management Network Commercial	$5.74
Rate for Payer: Kaiser Permanente Commercial	$6.08
Rate for Payer: MDX Hawaii PPO	$6.55

butalbital-APAP-caffeine 50-325-40 mg Tab [KMC]

Facility

$6.75

Service Code	NDC 69367020301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$6.55
Rate for Payer: AlohaCare Medicaid	$3.38
Rate for Payer: AlohaCare Medicare	$2.83
Rate for Payer: Cash Price	$4.39
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.21
Rate for Payer: Devoted Health Medicare	$2.83
Rate for Payer: Hawaii Medical Service Association Medicare	$2.83
Rate for Payer: Hawaii Western Management Group Commercial	$6.41
Rate for Payer: Health Management Network Commercial	$5.74
Rate for Payer: Humana Medicare	$2.83
Rate for Payer: Kaiser Permanente Commercial	$6.08
Rate for Payer: Kaiser Permanente Medicaid	$3.44
Rate for Payer: Kaiser Permanente Medicare	$2.83
Rate for Payer: MDX Hawaii PPO	$6.55
Rate for Payer: Ohana Health Plan Medicaid	$2.83
Rate for Payer: Ohana Health Plan Medicare	$2.83
Rate for Payer: UnitedHealthcare Medicaid	$4.05
Rate for Payer: UnitedHealthcare Medicare	$2.83
Rate for Payer: University Health Alliance Commercial	$4.92

C3 Complement DLS

Facility

$219.00

Service Code	HCPCS 86160
Hospital Charge Code	422861605
Hospital Revenue Code	301
Min. Negotiated Rate	$186.15
Max. Negotiated Rate	$212.43
Rate for Payer: Cash Price	$142.35
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: Kaiser Permanente Commercial	$197.10
Rate for Payer: MDX Hawaii PPO	$212.43

C3 Complement DLS

Facility

$219.00

Service Code	HCPCS 86160
Hospital Charge Code	422861605
Hospital Revenue Code	301
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$212.43
Rate for Payer: AlohaCare Medicaid	$109.50
Rate for Payer: AlohaCare Medicare	$91.98
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$201.48
Rate for Payer: Devoted Health Medicare	$91.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.59
Rate for Payer: Hawaii Medical Service Association Commercial	$15.00
Rate for Payer: Hawaii Medical Service Association Medicare	$91.98
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: Humana Medicare	$91.98
Rate for Payer: Kaiser Permanente Commercial	$197.10
Rate for Payer: Kaiser Permanente Medicaid	$111.69
Rate for Payer: Kaiser Permanente Medicare	$91.98
Rate for Payer: MDX Hawaii PPO	$212.43
Rate for Payer: Ohana Health Plan Medicaid	$91.98
Rate for Payer: Ohana Health Plan Medicare	$91.98
Rate for Payer: UnitedHealthcare Medicaid	$16.59
Rate for Payer: UnitedHealthcare Medicare	$91.98
Rate for Payer: University Health Alliance Commercial	$31.04

C4 Complement DLS

Facility

$54.00

Service Code	HCPCS 86160
Hospital Charge Code	422861605
Hospital Revenue Code	301
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

C4 Complement DLS

Facility

$54.00

Service Code	HCPCS 86160
Hospital Charge Code	422861605
Hospital Revenue Code	301
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$22.68
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$49.68
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.59
Rate for Payer: Hawaii Medical Service Association Commercial	$15.00
Rate for Payer: Hawaii Medical Service Association Medicare	$22.68
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$22.68
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$22.68
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$22.68
Rate for Payer: Ohana Health Plan Medicare	$22.68
Rate for Payer: UnitedHealthcare Medicaid	$16.59
Rate for Payer: UnitedHealthcare Medicare	$22.68
Rate for Payer: University Health Alliance Commercial	$31.04

CA 125 DLS

Facility

$377.00

Service Code	HCPCS 86304
Hospital Charge Code	422863045
Hospital Revenue Code	301
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$365.69
Rate for Payer: AlohaCare Medicaid	$188.50
Rate for Payer: AlohaCare Medicare	$158.34
Rate for Payer: Cash Price	$245.05
Rate for Payer: Cash Price	$245.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$346.84
Rate for Payer: Devoted Health Medicare	$158.34
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$28.76
Rate for Payer: Hawaii Medical Service Association Commercial	$26.01
Rate for Payer: Hawaii Medical Service Association Medicare	$158.34
Rate for Payer: Hawaii Western Management Group Commercial	$20.81
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: Humana Medicare	$158.34
Rate for Payer: Kaiser Permanente Commercial	$339.30
Rate for Payer: Kaiser Permanente Medicaid	$192.27
Rate for Payer: Kaiser Permanente Medicare	$158.34
Rate for Payer: MDX Hawaii PPO	$365.69
Rate for Payer: Ohana Health Plan Medicaid	$158.34
Rate for Payer: Ohana Health Plan Medicare	$158.34
Rate for Payer: UnitedHealthcare Medicaid	$28.76
Rate for Payer: UnitedHealthcare Medicare	$158.34
Rate for Payer: University Health Alliance Commercial	$53.78

CA 125 DLS

Facility

$377.00

Service Code	HCPCS 86304
Hospital Charge Code	422863045
Hospital Revenue Code	301
Min. Negotiated Rate	$320.45
Max. Negotiated Rate	$365.69
Rate for Payer: Cash Price	$245.05
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: Kaiser Permanente Commercial	$339.30
Rate for Payer: MDX Hawaii PPO	$365.69

CA 15-3 DLS

Facility

$435.00

Service Code	HCPCS 86300
Hospital Charge Code	422863005
Hospital Revenue Code	301
Min. Negotiated Rate	$369.75
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$282.75
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: MDX Hawaii PPO	$421.95

Know your out-of-pocket cost for care.

All Charges