Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

calcium gluconate 1 gm / 10 mL vial [KMC]

Facility

$4.81

Service Code	HCPCS J0610
Hospital Revenue Code	636
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$4.67
Rate for Payer: AlohaCare Medicaid	$2.40
Rate for Payer: AlohaCare Medicare	$2.02
Rate for Payer: Cash Price	$3.13
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.43
Rate for Payer: Devoted Health Medicare	$2.02
Rate for Payer: Hawaii Medical Service Association Medicare	$2.02
Rate for Payer: Hawaii Western Management Group Commercial	$4.57
Rate for Payer: Health Management Network Commercial	$4.09
Rate for Payer: Humana Medicare	$2.02
Rate for Payer: Kaiser Permanente Commercial	$4.33
Rate for Payer: Kaiser Permanente Medicaid	$2.45
Rate for Payer: Kaiser Permanente Medicare	$2.02
Rate for Payer: MDX Hawaii PPO	$4.67
Rate for Payer: Ohana Health Plan Medicaid	$2.02
Rate for Payer: Ohana Health Plan Medicare	$2.02
Rate for Payer: UnitedHealthcare Medicaid	$2.89
Rate for Payer: UnitedHealthcare Medicare	$2.02
Rate for Payer: University Health Alliance Commercial	$3.51

calcium gluconate 1 gm / 10 mL vial [KMC]

Facility

$4.81

Service Code	HCPCS J0610
Hospital Revenue Code	636
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$4.67
Rate for Payer: Cash Price	$3.13
Rate for Payer: Health Management Network Commercial	$4.09
Rate for Payer: Kaiser Permanente Commercial	$4.33
Rate for Payer: MDX Hawaii PPO	$4.67

Calcium Level Total

Facility

$94.00

Service Code	HCPCS 82310
Hospital Charge Code	422823100
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 Level Total

Facility

$94.00

Service Code	HCPCS 82310
Hospital Charge Code	422823100
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

calcium-vit D 600mg-400units Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

calcium-vit D 600mg-400units Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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

Calprotectin, Fecal DLS

Facility

$264.00

Service Code	HCPCS 83993
Hospital Charge Code	422839935
Hospital Revenue Code	300
Min. Negotiated Rate	$224.40
Max. Negotiated Rate	$256.08
Rate for Payer: Cash Price	$171.60
Rate for Payer: Health Management Network Commercial	$224.40
Rate for Payer: Kaiser Permanente Commercial	$237.60
Rate for Payer: MDX Hawaii PPO	$256.08

Calprotectin, Fecal DLS

Facility

$264.00

Service Code	HCPCS 83993
Hospital Charge Code	422839935
Hospital Revenue Code	300
Min. Negotiated Rate	$19.63
Max. Negotiated Rate	$256.08
Rate for Payer: AlohaCare Medicaid	$132.00
Rate for Payer: AlohaCare Medicare	$110.88
Rate for Payer: Cash Price	$171.60
Rate for Payer: Cash Price	$171.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$242.88
Rate for Payer: Devoted Health Medicare	$110.88
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$27.42
Rate for Payer: Hawaii Medical Service Association Commercial	$24.54
Rate for Payer: Hawaii Medical Service Association Medicare	$110.88
Rate for Payer: Hawaii Western Management Group Commercial	$19.63
Rate for Payer: Health Management Network Commercial	$224.40
Rate for Payer: Humana Medicare	$110.88
Rate for Payer: Kaiser Permanente Commercial	$237.60
Rate for Payer: Kaiser Permanente Medicaid	$134.64
Rate for Payer: Kaiser Permanente Medicare	$110.88
Rate for Payer: MDX Hawaii PPO	$256.08
Rate for Payer: Ohana Health Plan Medicaid	$110.88
Rate for Payer: Ohana Health Plan Medicare	$110.88
Rate for Payer: UnitedHealthcare Medicaid	$27.42
Rate for Payer: UnitedHealthcare Medicare	$110.88
Rate for Payer: University Health Alliance Commercial	$50.73

camphor-menthol (Tiger Balm) Ointment [KMC]

Facility

$0.67

Service Code	NDC 39278031541
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.44
Rate for Payer: Health Management Network Commercial	$0.57
Rate for Payer: Kaiser Permanente Commercial	$0.60
Rate for Payer: MDX Hawaii PPO	$0.65

camphor-menthol (Tiger Balm) Ointment [KMC]

Facility

$0.67

Service Code	NDC 39278031541
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.65
Rate for Payer: AlohaCare Medicaid	$0.34
Rate for Payer: AlohaCare Medicare	$0.28
Rate for Payer: Cash Price	$0.44
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.62
Rate for Payer: Devoted Health Medicare	$0.28
Rate for Payer: Hawaii Medical Service Association Medicare	$0.28
Rate for Payer: Hawaii Western Management Group Commercial	$0.64
Rate for Payer: Health Management Network Commercial	$0.57
Rate for Payer: Humana Medicare	$0.28
Rate for Payer: Kaiser Permanente Commercial	$0.60
Rate for Payer: Kaiser Permanente Medicaid	$0.34
Rate for Payer: Kaiser Permanente Medicare	$0.28
Rate for Payer: MDX Hawaii PPO	$0.65
Rate for Payer: Ohana Health Plan Medicaid	$0.28
Rate for Payer: Ohana Health Plan Medicare	$0.28
Rate for Payer: UnitedHealthcare Medicaid	$0.40
Rate for Payer: UnitedHealthcare Medicare	$0.28
Rate for Payer: University Health Alliance Commercial	$0.49

capsaicin 0.075% Cream [KMC]

Facility

$1.80

Service Code	NDC 00603064988
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.75
Rate for Payer: AlohaCare Medicaid	$0.90
Rate for Payer: AlohaCare Medicare	$0.76
Rate for Payer: Cash Price	$1.17
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.66
Rate for Payer: Devoted Health Medicare	$0.76
Rate for Payer: Hawaii Medical Service Association Medicare	$0.76
Rate for Payer: Hawaii Western Management Group Commercial	$1.71
Rate for Payer: Health Management Network Commercial	$1.53
Rate for Payer: Humana Medicare	$0.76
Rate for Payer: Kaiser Permanente Commercial	$1.62
Rate for Payer: Kaiser Permanente Medicaid	$0.92
Rate for Payer: Kaiser Permanente Medicare	$0.76
Rate for Payer: MDX Hawaii PPO	$1.75
Rate for Payer: Ohana Health Plan Medicaid	$0.76
Rate for Payer: Ohana Health Plan Medicare	$0.76
Rate for Payer: UnitedHealthcare Medicaid	$1.08
Rate for Payer: UnitedHealthcare Medicare	$0.76
Rate for Payer: University Health Alliance Commercial	$1.31

capsaicin 0.075% Cream [KMC]

Facility

$1.80

Service Code	NDC 00603064988
Hospital Revenue Code	250
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$1.75
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Management Network Commercial	$1.53
Rate for Payer: Kaiser Permanente Commercial	$1.62
Rate for Payer: MDX Hawaii PPO	$1.75

carBAMazepine 100 mg/5 mL Susp [KMC]

Facility

$0.79

Service Code	NDC 70954024010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.77
Rate for Payer: AlohaCare Medicaid	$0.40
Rate for Payer: AlohaCare Medicare	$0.33
Rate for Payer: Cash Price	$0.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.73
Rate for Payer: Devoted Health Medicare	$0.33
Rate for Payer: Hawaii Medical Service Association Medicare	$0.33
Rate for Payer: Hawaii Western Management Group Commercial	$0.75
Rate for Payer: Health Management Network Commercial	$0.67
Rate for Payer: Humana Medicare	$0.33
Rate for Payer: Kaiser Permanente Commercial	$0.71
Rate for Payer: Kaiser Permanente Medicaid	$0.40
Rate for Payer: Kaiser Permanente Medicare	$0.33
Rate for Payer: MDX Hawaii PPO	$0.77
Rate for Payer: Ohana Health Plan Medicaid	$0.33
Rate for Payer: Ohana Health Plan Medicare	$0.33
Rate for Payer: UnitedHealthcare Medicaid	$0.47
Rate for Payer: UnitedHealthcare Medicare	$0.33
Rate for Payer: University Health Alliance Commercial	$0.58

carBAMazepine 100 mg/5 mL Susp [KMC]

Facility

$0.79

Service Code	NDC 70954024010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Management Network Commercial	$0.67
Rate for Payer: Kaiser Permanente Commercial	$0.71
Rate for Payer: MDX Hawaii PPO	$0.77

carBAMazepine 100 mg Chew tab [KMC]

Facility

$3.00

Service Code	NDC 13668027101
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

carBAMazepine 100 mg Chew tab [KMC]

Facility

$3.00

Service Code	NDC 13668027101
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

carBAMazepine 200 mg ER tab [KMC]

Facility

$6.45

Service Code	NDC 16714006401
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$6.26
Rate for Payer: AlohaCare Medicaid	$3.23
Rate for Payer: AlohaCare Medicare	$2.71
Rate for Payer: Cash Price	$4.19
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.93
Rate for Payer: Devoted Health Medicare	$2.71
Rate for Payer: Hawaii Medical Service Association Medicare	$2.71
Rate for Payer: Hawaii Western Management Group Commercial	$6.13
Rate for Payer: Health Management Network Commercial	$5.48
Rate for Payer: Humana Medicare	$2.71
Rate for Payer: Kaiser Permanente Commercial	$5.80
Rate for Payer: Kaiser Permanente Medicaid	$3.29
Rate for Payer: Kaiser Permanente Medicare	$2.71
Rate for Payer: MDX Hawaii PPO	$6.26
Rate for Payer: Ohana Health Plan Medicaid	$2.71
Rate for Payer: Ohana Health Plan Medicare	$2.71
Rate for Payer: UnitedHealthcare Medicaid	$3.87
Rate for Payer: UnitedHealthcare Medicare	$2.71
Rate for Payer: University Health Alliance Commercial	$4.70

carBAMazepine 200 mg ER tab [KMC]

Facility

$6.45

Service Code	NDC 16714006401
Hospital Revenue Code	250
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$6.26
Rate for Payer: Cash Price	$4.19
Rate for Payer: Health Management Network Commercial	$5.48
Rate for Payer: Kaiser Permanente Commercial	$5.80
Rate for Payer: MDX Hawaii PPO	$6.26

carBAMazepine 200 mg Tab [KMC]

Facility

$6.40

Service Code	NDC 75834022101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$6.21
Rate for Payer: AlohaCare Medicaid	$3.20
Rate for Payer: AlohaCare Medicare	$2.69
Rate for Payer: Cash Price	$4.16
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.89
Rate for Payer: Devoted Health Medicare	$2.69
Rate for Payer: Hawaii Medical Service Association Medicare	$2.69
Rate for Payer: Hawaii Western Management Group Commercial	$6.08
Rate for Payer: Health Management Network Commercial	$5.44
Rate for Payer: Humana Medicare	$2.69
Rate for Payer: Kaiser Permanente Commercial	$5.76
Rate for Payer: Kaiser Permanente Medicaid	$3.26
Rate for Payer: Kaiser Permanente Medicare	$2.69
Rate for Payer: MDX Hawaii PPO	$6.21
Rate for Payer: Ohana Health Plan Medicaid	$2.69
Rate for Payer: Ohana Health Plan Medicare	$2.69
Rate for Payer: UnitedHealthcare Medicaid	$3.84
Rate for Payer: UnitedHealthcare Medicare	$2.69
Rate for Payer: University Health Alliance Commercial	$4.66

carBAMazepine 200 mg Tab [KMC]

Facility

$6.40

Service Code	NDC 75834022101
Hospital Revenue Code	250
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$6.21
Rate for Payer: Cash Price	$4.16
Rate for Payer: Health Management Network Commercial	$5.44
Rate for Payer: Kaiser Permanente Commercial	$5.76
Rate for Payer: MDX Hawaii PPO	$6.21

Carbamazepine (Tegretol) DLS

Facility

$193.00

Service Code	HCPCS 80156
Hospital Charge Code	422801565
Hospital Revenue Code	301
Min. Negotiated Rate	$164.05
Max. Negotiated Rate	$187.21
Rate for Payer: Cash Price	$125.45
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: MDX Hawaii PPO	$187.21

Carbamazepine (Tegretol) DLS

Facility

$193.00

Service Code	HCPCS 80156
Hospital Charge Code	422801565
Hospital Revenue Code	301
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$187.21
Rate for Payer: AlohaCare Medicaid	$96.50
Rate for Payer: AlohaCare Medicare	$81.06
Rate for Payer: Cash Price	$125.45
Rate for Payer: Cash Price	$125.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$177.56
Rate for Payer: Devoted Health Medicare	$81.06
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.12
Rate for Payer: Hawaii Medical Service Association Commercial	$18.21
Rate for Payer: Hawaii Medical Service Association Medicare	$81.06
Rate for Payer: Hawaii Western Management Group Commercial	$14.57
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Humana Medicare	$81.06
Rate for Payer: Kaiser Permanente Commercial	$173.70
Rate for Payer: Kaiser Permanente Medicaid	$98.43
Rate for Payer: Kaiser Permanente Medicare	$81.06
Rate for Payer: MDX Hawaii PPO	$187.21
Rate for Payer: Ohana Health Plan Medicaid	$81.06
Rate for Payer: Ohana Health Plan Medicare	$81.06
Rate for Payer: UnitedHealthcare Medicaid	$20.12
Rate for Payer: UnitedHealthcare Medicare	$81.06
Rate for Payer: University Health Alliance Commercial	$37.63

carbamide peroxide Otic 6.5% Sol [KMC]

Facility

$0.46

Service Code	NDC 00904662735
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.45
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Management Network Commercial	$0.39
Rate for Payer: Kaiser Permanente Commercial	$0.41
Rate for Payer: MDX Hawaii PPO	$0.45

carbamide peroxide Otic 6.5% Sol [KMC]

Facility

$0.46

Service Code	NDC 00904662735
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.45
Rate for Payer: AlohaCare Medicaid	$0.23
Rate for Payer: AlohaCare Medicare	$0.19
Rate for Payer: Cash Price	$0.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.42
Rate for Payer: Devoted Health Medicare	$0.19
Rate for Payer: Hawaii Medical Service Association Medicare	$0.19
Rate for Payer: Hawaii Western Management Group Commercial	$0.44
Rate for Payer: Health Management Network Commercial	$0.39
Rate for Payer: Humana Medicare	$0.19
Rate for Payer: Kaiser Permanente Commercial	$0.41
Rate for Payer: Kaiser Permanente Medicaid	$0.23
Rate for Payer: Kaiser Permanente Medicare	$0.19
Rate for Payer: MDX Hawaii PPO	$0.45
Rate for Payer: Ohana Health Plan Medicaid	$0.19
Rate for Payer: Ohana Health Plan Medicare	$0.19
Rate for Payer: UnitedHealthcare Medicaid	$0.28
Rate for Payer: UnitedHealthcare Medicare	$0.19
Rate for Payer: University Health Alliance Commercial	$0.34

carbidopa/entacapone/levodopa 25 mg-200 mg-100 mg Tab [KMC]

Facility

$15.00

Service Code	NDC 00378830201
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$6.30
Rate for Payer: Cash Price	$9.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.80
Rate for Payer: Devoted Health Medicare	$6.30
Rate for Payer: Hawaii Medical Service Association Medicare	$6.30
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$6.30
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$6.30
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$6.30
Rate for Payer: Ohana Health Plan Medicare	$6.30
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: UnitedHealthcare Medicare	$6.30
Rate for Payer: University Health Alliance Commercial	$10.93

Know your out-of-pocket cost for care.

All Charges