Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

CA 19-9 DLS

Facility

$200.00

Service Code	HCPCS 86301
Hospital Charge Code	422863015
Hospital Revenue Code	301
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

CA 19-9 DLS

Facility

$200.00

Service Code	HCPCS 86301
Hospital Charge Code	422863015
Hospital Revenue Code	301
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$84.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$184.00
Rate for Payer: Devoted Health Medicare	$84.00
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	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$20.81
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$84.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$84.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$84.00
Rate for Payer: Ohana Health Plan Medicare	$84.00
Rate for Payer: UnitedHealthcare Medicaid	$28.76
Rate for Payer: UnitedHealthcare Medicare	$84.00
Rate for Payer: University Health Alliance Commercial	$53.78

CA 27.29 DLS

Facility

$435.00

Service Code	HCPCS 86300
Hospital Charge Code	422863005
Hospital Revenue Code	301
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$421.95
Rate for Payer: AlohaCare Medicaid	$217.50
Rate for Payer: AlohaCare Medicare	$182.70
Rate for Payer: Cash Price	$282.75
Rate for Payer: Cash Price	$282.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$400.20
Rate for Payer: Devoted Health Medicare	$182.70
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	$182.70
Rate for Payer: Hawaii Western Management Group Commercial	$20.81
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Humana Medicare	$182.70
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: Kaiser Permanente Medicare	$182.70
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: Ohana Health Plan Medicaid	$182.70
Rate for Payer: Ohana Health Plan Medicare	$182.70
Rate for Payer: UnitedHealthcare Medicaid	$28.76
Rate for Payer: UnitedHealthcare Medicare	$182.70
Rate for Payer: University Health Alliance Commercial	$53.78

CA 27.29 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

cadexomer iodine 0.9% Gel [KMC]

Facility

$13.71

Service Code	NDC 40565012249
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$13.30
Rate for Payer: AlohaCare Medicaid	$6.86
Rate for Payer: AlohaCare Medicare	$5.76
Rate for Payer: Cash Price	$8.91
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.61
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Hawaii Medical Service Association Medicare	$5.76
Rate for Payer: Hawaii Western Management Group Commercial	$13.02
Rate for Payer: Health Management Network Commercial	$11.65
Rate for Payer: Humana Medicare	$5.76
Rate for Payer: Kaiser Permanente Commercial	$12.34
Rate for Payer: Kaiser Permanente Medicaid	$6.99
Rate for Payer: Kaiser Permanente Medicare	$5.76
Rate for Payer: MDX Hawaii PPO	$13.30
Rate for Payer: Ohana Health Plan Medicaid	$5.76
Rate for Payer: Ohana Health Plan Medicare	$5.76
Rate for Payer: UnitedHealthcare Medicaid	$8.23
Rate for Payer: UnitedHealthcare Medicare	$5.76
Rate for Payer: University Health Alliance Commercial	$9.99

cadexomer iodine 0.9% Gel [KMC]

Facility

$13.71

Service Code	NDC 40565012249
Hospital Revenue Code	250
Min. Negotiated Rate	$11.65
Max. Negotiated Rate	$13.30
Rate for Payer: Cash Price	$8.91
Rate for Payer: Health Management Network Commercial	$11.65
Rate for Payer: Kaiser Permanente Commercial	$12.34
Rate for Payer: MDX Hawaii PPO	$13.30

calamine-pramoxine 8-1% (Caldyphen) Lotion

Facility

$0.10

Service Code	NDC 49348033736
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: MDX Hawaii PPO	$0.10

calamine-pramoxine 8-1% (Caldyphen) Lotion

Facility

$0.10

Service Code	NDC 49348033736
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: AlohaCare Medicaid	$0.05
Rate for Payer: AlohaCare Medicare	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$0.10
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.10
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.06
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

CALCANEUS MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73650
Hospital Charge Code	424736500
Hospital Revenue Code	320
Min. Negotiated Rate	$17.03
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$17.03
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$17.03
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$53.87

CALCANEUS MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73650
Hospital Charge Code	424736500
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

calcitonin 200 intl units/inh Nasal Spry [KMC]

Facility

$128.15

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$108.93
Max. Negotiated Rate	$124.31
Rate for Payer: Cash Price	$83.30
Rate for Payer: Health Management Network Commercial	$108.93
Rate for Payer: Kaiser Permanente Commercial	$115.33
Rate for Payer: MDX Hawaii PPO	$124.31

calcitonin 200 intl units/inh Nasal Spry [KMC]

Facility

$128.15

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$53.82
Max. Negotiated Rate	$124.31
Rate for Payer: AlohaCare Medicaid	$64.08
Rate for Payer: AlohaCare Medicare	$53.82
Rate for Payer: Cash Price	$83.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$117.90
Rate for Payer: Devoted Health Medicare	$53.82
Rate for Payer: Hawaii Medical Service Association Medicare	$53.82
Rate for Payer: Hawaii Western Management Group Commercial	$121.74
Rate for Payer: Health Management Network Commercial	$108.93
Rate for Payer: Humana Medicare	$53.82
Rate for Payer: Kaiser Permanente Commercial	$115.33
Rate for Payer: Kaiser Permanente Medicaid	$65.36
Rate for Payer: Kaiser Permanente Medicare	$53.82
Rate for Payer: MDX Hawaii PPO	$124.31
Rate for Payer: Ohana Health Plan Medicaid	$53.82
Rate for Payer: Ohana Health Plan Medicare	$53.82
Rate for Payer: UnitedHealthcare Medicare	$53.82
Rate for Payer: University Health Alliance Commercial	$93.41

calcitriol 0.25 mcg Oral Cap [KMC]

Facility

$5.12

Service Code	NDC 64380072304
Hospital Revenue Code	250
Min. Negotiated Rate	$4.35
Max. Negotiated Rate	$4.97
Rate for Payer: Cash Price	$3.33
Rate for Payer: Health Management Network Commercial	$4.35
Rate for Payer: Kaiser Permanente Commercial	$4.61
Rate for Payer: MDX Hawaii PPO	$4.97

calcitriol 0.25 mcg Oral Cap [KMC]

Facility

$5.12

Service Code	NDC 64380072304
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$4.97
Rate for Payer: AlohaCare Medicaid	$2.56
Rate for Payer: AlohaCare Medicare	$2.15
Rate for Payer: Cash Price	$3.33
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.71
Rate for Payer: Devoted Health Medicare	$2.15
Rate for Payer: Hawaii Medical Service Association Medicare	$2.15
Rate for Payer: Hawaii Western Management Group Commercial	$4.86
Rate for Payer: Health Management Network Commercial	$4.35
Rate for Payer: Humana Medicare	$2.15
Rate for Payer: Kaiser Permanente Commercial	$4.61
Rate for Payer: Kaiser Permanente Medicaid	$2.61
Rate for Payer: Kaiser Permanente Medicare	$2.15
Rate for Payer: MDX Hawaii PPO	$4.97
Rate for Payer: Ohana Health Plan Medicaid	$2.15
Rate for Payer: Ohana Health Plan Medicare	$2.15
Rate for Payer: UnitedHealthcare Medicaid	$3.07
Rate for Payer: UnitedHealthcare Medicare	$2.15
Rate for Payer: University Health Alliance Commercial	$3.73

calcium acetate 667 mg Cap [KMC]

Facility

$4.11

Service Code	NDC 23155053102
Hospital Revenue Code	250
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$3.99
Rate for Payer: Cash Price	$2.67
Rate for Payer: Health Management Network Commercial	$3.49
Rate for Payer: Kaiser Permanente Commercial	$3.70
Rate for Payer: MDX Hawaii PPO	$3.99

calcium acetate 667 mg Cap [KMC]

Facility

$4.11

Service Code	NDC 23155053102
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.99
Rate for Payer: AlohaCare Medicaid	$2.06
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$2.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.78
Rate for Payer: Devoted Health Medicare	$1.73
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.90
Rate for Payer: Health Management Network Commercial	$3.49
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$3.70
Rate for Payer: Kaiser Permanente Medicaid	$2.10
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$3.99
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$2.47
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$3.00

calcium acetate 667 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 71321080320
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

calcium acetate 667 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 71321080320
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

calcium carbonate (TUMS) 500 mg chew tab [KMC]

Facility

$3.00

Service Code	NDC 00904125792
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

calcium carbonate (TUMS) 500 mg chew tab [KMC]

Facility

$3.00

Service Code	NDC 00904125792
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

calcium chloride 1 gm / 10 mL syringe [KMC]

Facility

$5.04

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$4.28
Max. Negotiated Rate	$4.89
Rate for Payer: Cash Price	$3.28
Rate for Payer: Health Management Network Commercial	$4.28
Rate for Payer: Kaiser Permanente Commercial	$4.54
Rate for Payer: MDX Hawaii PPO	$4.89

calcium chloride 1 gm / 10 mL syringe [KMC]

Facility

$5.04

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$4.89
Rate for Payer: AlohaCare Medicaid	$2.52
Rate for Payer: AlohaCare Medicare	$2.12
Rate for Payer: Cash Price	$3.28
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.64
Rate for Payer: Devoted Health Medicare	$2.12
Rate for Payer: Hawaii Medical Service Association Medicare	$2.12
Rate for Payer: Hawaii Western Management Group Commercial	$4.79
Rate for Payer: Health Management Network Commercial	$4.28
Rate for Payer: Humana Medicare	$2.12
Rate for Payer: Kaiser Permanente Commercial	$4.54
Rate for Payer: Kaiser Permanente Medicaid	$2.57
Rate for Payer: Kaiser Permanente Medicare	$2.12
Rate for Payer: MDX Hawaii PPO	$4.89
Rate for Payer: Ohana Health Plan Medicaid	$2.12
Rate for Payer: Ohana Health Plan Medicare	$2.12
Rate for Payer: UnitedHealthcare Medicaid	$3.02
Rate for Payer: UnitedHealthcare Medicare	$2.12
Rate for Payer: University Health Alliance Commercial	$3.67

Calcium DLS

Facility

$94.00

Service Code	HCPCS 82310
Hospital Charge Code	422823105
Hospital Revenue Code	301
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$61.10
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: MDX Hawaii PPO	$91.18

Calcium DLS

Facility

$94.00

Service Code	HCPCS 82310
Hospital Charge Code	422823105
Hospital Revenue Code	301
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$91.18
Rate for Payer: AlohaCare Medicaid	$47.00
Rate for Payer: AlohaCare Medicare	$39.48
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$86.48
Rate for Payer: Devoted Health Medicare	$39.48
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.12
Rate for Payer: Hawaii Medical Service Association Commercial	$6.45
Rate for Payer: Hawaii Medical Service Association Medicare	$39.48
Rate for Payer: Hawaii Western Management Group Commercial	$5.16
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Humana Medicare	$39.48
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: Kaiser Permanente Medicare	$39.48
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: Ohana Health Plan Medicaid	$39.48
Rate for Payer: Ohana Health Plan Medicare	$39.48
Rate for Payer: UnitedHealthcare Medicaid	$7.12
Rate for Payer: UnitedHealthcare Medicare	$39.48
Rate for Payer: University Health Alliance Commercial	$13.32

Know your out-of-pocket cost for care.

All Charges