Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

cefTAZidime 1 gm REC Injection [KMC]

Facility

$21.60

Service Code	HCPCS J0713
Hospital Revenue Code	636
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$20.95
Rate for Payer: Cash Price	$14.04
Rate for Payer: Health Management Network Commercial	$18.36
Rate for Payer: Kaiser Permanente Commercial	$19.44
Rate for Payer: MDX Hawaii PPO	$20.95

cefTAZidime 1 gm REC Injection [KMC]

Facility

$21.60

Service Code	HCPCS J0713
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$20.95
Rate for Payer: AlohaCare Medicaid	$10.80
Rate for Payer: AlohaCare Medicare	$9.07
Rate for Payer: Cash Price	$14.04
Rate for Payer: Cash Price	$14.04
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$19.87
Rate for Payer: Devoted Health Medicare	$9.07
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.09
Rate for Payer: Hawaii Medical Service Association Medicare	$9.07
Rate for Payer: Hawaii Western Management Group Commercial	$20.52
Rate for Payer: Health Management Network Commercial	$18.36
Rate for Payer: Humana Medicare	$9.07
Rate for Payer: Kaiser Permanente Commercial	$19.44
Rate for Payer: Kaiser Permanente Medicaid	$11.02
Rate for Payer: Kaiser Permanente Medicare	$9.07
Rate for Payer: MDX Hawaii PPO	$20.95
Rate for Payer: Ohana Health Plan Medicaid	$9.07
Rate for Payer: Ohana Health Plan Medicare	$9.07
Rate for Payer: UnitedHealthcare Medicaid	$12.96
Rate for Payer: UnitedHealthcare Medicare	$9.07
Rate for Payer: University Health Alliance Commercial	$15.74

cefTAZidime 2 gm REC Injection [KMC]

Facility

$48.00

Service Code	HCPCS J0713
Hospital Revenue Code	636
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$20.16
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$44.16
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.09
Rate for Payer: Hawaii Medical Service Association Medicare	$20.16
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$20.16
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$20.16
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$20.16
Rate for Payer: Ohana Health Plan Medicare	$20.16
Rate for Payer: UnitedHealthcare Medicaid	$28.80
Rate for Payer: UnitedHealthcare Medicare	$20.16
Rate for Payer: University Health Alliance Commercial	$34.99

cefTAZidime 2 gm REC Injection [KMC]

Facility

$48.00

Service Code	HCPCS J0713
Hospital Revenue Code	636
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$31.20
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

ceftolozane-tazobactam 1.5 gm vial [KMC]

Facility

$601.06

Service Code	HCPCS J0695
Hospital Revenue Code	636
Min. Negotiated Rate	$9.13
Max. Negotiated Rate	$583.03
Rate for Payer: AlohaCare Medicaid	$300.53
Rate for Payer: AlohaCare Medicare	$252.45
Rate for Payer: Cash Price	$390.69
Rate for Payer: Cash Price	$390.69
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$552.98
Rate for Payer: Devoted Health Medicare	$252.45
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.13
Rate for Payer: Hawaii Medical Service Association Commercial	$11.05
Rate for Payer: Hawaii Medical Service Association Medicare	$252.45
Rate for Payer: Hawaii Western Management Group Commercial	$571.01
Rate for Payer: Health Management Network Commercial	$510.90
Rate for Payer: Humana Medicare	$252.45
Rate for Payer: Kaiser Permanente Commercial	$540.95
Rate for Payer: Kaiser Permanente Medicaid	$306.54
Rate for Payer: Kaiser Permanente Medicare	$252.45
Rate for Payer: MDX Hawaii PPO	$583.03
Rate for Payer: Ohana Health Plan Medicaid	$252.45
Rate for Payer: Ohana Health Plan Medicare	$252.45
Rate for Payer: UnitedHealthcare Medicaid	$360.64
Rate for Payer: UnitedHealthcare Medicare	$252.45
Rate for Payer: University Health Alliance Commercial	$438.11

ceftolozane-tazobactam 1.5 gm vial [KMC]

Facility

$601.06

Service Code	HCPCS J0695
Hospital Revenue Code	636
Min. Negotiated Rate	$510.90
Max. Negotiated Rate	$583.03
Rate for Payer: Cash Price	$390.69
Rate for Payer: Health Management Network Commercial	$510.90
Rate for Payer: Kaiser Permanente Commercial	$540.95
Rate for Payer: MDX Hawaii PPO	$583.03

cefTRIAXone 1 g Inj [KMC]

Facility

$7.31

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$3.65
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$4.75
Rate for Payer: Cash Price	$4.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.73
Rate for Payer: Devoted Health Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.70
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Western Management Group Commercial	$6.94
Rate for Payer: Health Management Network Commercial	$6.21
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$6.58
Rate for Payer: Kaiser Permanente Medicaid	$3.73
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$7.09
Rate for Payer: Ohana Health Plan Medicaid	$3.07
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$4.39
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$5.33

cefTRIAXone 1 g Inj [KMC]

Facility

$7.31

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$6.21
Max. Negotiated Rate	$7.09
Rate for Payer: Cash Price	$4.75
Rate for Payer: Health Management Network Commercial	$6.21
Rate for Payer: Kaiser Permanente Commercial	$6.58
Rate for Payer: MDX Hawaii PPO	$7.09

cefTRIAXone 2 g REC [KMC]

Facility

$13.89

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$5.83
Max. Negotiated Rate	$13.47
Rate for Payer: AlohaCare Medicaid	$6.95
Rate for Payer: AlohaCare Medicare	$5.83
Rate for Payer: Cash Price	$9.03
Rate for Payer: Cash Price	$9.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.78
Rate for Payer: Devoted Health Medicare	$5.83
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.70
Rate for Payer: Hawaii Medical Service Association Medicare	$5.83
Rate for Payer: Hawaii Western Management Group Commercial	$13.20
Rate for Payer: Health Management Network Commercial	$11.81
Rate for Payer: Humana Medicare	$5.83
Rate for Payer: Kaiser Permanente Commercial	$12.50
Rate for Payer: Kaiser Permanente Medicaid	$7.08
Rate for Payer: Kaiser Permanente Medicare	$5.83
Rate for Payer: MDX Hawaii PPO	$13.47
Rate for Payer: Ohana Health Plan Medicaid	$5.83
Rate for Payer: Ohana Health Plan Medicare	$5.83
Rate for Payer: UnitedHealthcare Medicaid	$8.33
Rate for Payer: UnitedHealthcare Medicare	$5.83
Rate for Payer: University Health Alliance Commercial	$10.12

cefTRIAXone 2 g REC [KMC]

Facility

$13.89

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$11.81
Max. Negotiated Rate	$13.47
Rate for Payer: Cash Price	$9.03
Rate for Payer: Health Management Network Commercial	$11.81
Rate for Payer: Kaiser Permanente Commercial	$12.50
Rate for Payer: MDX Hawaii PPO	$13.47

CEFTRIAXONE SODIUM INJECTION

Professional

Both

$6.00

Service Code	HCPCS J0696
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$10.34
Rate for Payer: AlohaCare Medicare	$0.43
Rate for Payer: Cash Price	$3.90
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$0.43
Rate for Payer: Hawaii Medical Service Association Medicare	$0.43
Rate for Payer: Hawaii Western Management Group Commercial	$10.34
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$0.52
Rate for Payer: Kaiser Permanente Medicaid	$0.52
Rate for Payer: Kaiser Permanente Medicare	$0.52
Rate for Payer: Ohana Health Plan Medicare	$0.43
Rate for Payer: UnitedHealthcare Medicare	$0.43

cefuroxime 500 mg Tab [KMC]

Facility

$44.42

Service Code	NDC 67877021620
Hospital Revenue Code	250
Min. Negotiated Rate	$37.76
Max. Negotiated Rate	$43.09
Rate for Payer: Cash Price	$28.87
Rate for Payer: Health Management Network Commercial	$37.76
Rate for Payer: Kaiser Permanente Commercial	$39.98
Rate for Payer: MDX Hawaii PPO	$43.09

cefuroxime 500 mg Tab [KMC]

Facility

$44.42

Service Code	NDC 67877021620
Hospital Revenue Code	250
Min. Negotiated Rate	$18.66
Max. Negotiated Rate	$43.09
Rate for Payer: AlohaCare Medicaid	$22.21
Rate for Payer: AlohaCare Medicare	$18.66
Rate for Payer: Cash Price	$28.87
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$40.87
Rate for Payer: Devoted Health Medicare	$18.66
Rate for Payer: Hawaii Medical Service Association Medicare	$18.66
Rate for Payer: Hawaii Western Management Group Commercial	$42.20
Rate for Payer: Health Management Network Commercial	$37.76
Rate for Payer: Humana Medicare	$18.66
Rate for Payer: Kaiser Permanente Commercial	$39.98
Rate for Payer: Kaiser Permanente Medicaid	$22.65
Rate for Payer: Kaiser Permanente Medicare	$18.66
Rate for Payer: MDX Hawaii PPO	$43.09
Rate for Payer: Ohana Health Plan Medicaid	$18.66
Rate for Payer: Ohana Health Plan Medicare	$18.66
Rate for Payer: UnitedHealthcare Medicaid	$26.65
Rate for Payer: UnitedHealthcare Medicare	$18.66
Rate for Payer: University Health Alliance Commercial	$32.38

celecoxib 100 mg Cap [KMC]

Facility

$18.46

Service Code	NDC 72241002305
Hospital Revenue Code	250
Min. Negotiated Rate	$15.69
Max. Negotiated Rate	$17.91
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$15.69
Rate for Payer: Kaiser Permanente Commercial	$16.61
Rate for Payer: MDX Hawaii PPO	$17.91

celecoxib 100 mg Cap [KMC]

Facility

$18.46

Service Code	NDC 72241002305
Hospital Revenue Code	250
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$17.91
Rate for Payer: AlohaCare Medicaid	$9.23
Rate for Payer: AlohaCare Medicare	$7.75
Rate for Payer: Cash Price	$12.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.98
Rate for Payer: Devoted Health Medicare	$7.75
Rate for Payer: Hawaii Medical Service Association Medicare	$7.75
Rate for Payer: Hawaii Western Management Group Commercial	$17.54
Rate for Payer: Health Management Network Commercial	$15.69
Rate for Payer: Humana Medicare	$7.75
Rate for Payer: Kaiser Permanente Commercial	$16.61
Rate for Payer: Kaiser Permanente Medicaid	$9.41
Rate for Payer: Kaiser Permanente Medicare	$7.75
Rate for Payer: MDX Hawaii PPO	$17.91
Rate for Payer: Ohana Health Plan Medicaid	$7.75
Rate for Payer: Ohana Health Plan Medicare	$7.75
Rate for Payer: UnitedHealthcare Medicaid	$11.08
Rate for Payer: UnitedHealthcare Medicare	$7.75
Rate for Payer: University Health Alliance Commercial	$13.46

celecoxib 200 mg Cap [KMC]

Facility

$30.15

Service Code	NDC 16714073301
Hospital Revenue Code	250
Min. Negotiated Rate	$25.63
Max. Negotiated Rate	$29.25
Rate for Payer: Cash Price	$19.60
Rate for Payer: Health Management Network Commercial	$25.63
Rate for Payer: Kaiser Permanente Commercial	$27.14
Rate for Payer: MDX Hawaii PPO	$29.25

celecoxib 200 mg Cap [KMC]

Facility

$30.15

Service Code	NDC 16714073301
Hospital Revenue Code	250
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$29.25
Rate for Payer: AlohaCare Medicaid	$15.07
Rate for Payer: AlohaCare Medicare	$12.66
Rate for Payer: Cash Price	$19.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$27.74
Rate for Payer: Devoted Health Medicare	$12.66
Rate for Payer: Hawaii Medical Service Association Medicare	$12.66
Rate for Payer: Hawaii Western Management Group Commercial	$28.64
Rate for Payer: Health Management Network Commercial	$25.63
Rate for Payer: Humana Medicare	$12.66
Rate for Payer: Kaiser Permanente Commercial	$27.14
Rate for Payer: Kaiser Permanente Medicaid	$15.38
Rate for Payer: Kaiser Permanente Medicare	$12.66
Rate for Payer: MDX Hawaii PPO	$29.25
Rate for Payer: Ohana Health Plan Medicaid	$12.66
Rate for Payer: Ohana Health Plan Medicare	$12.66
Rate for Payer: UnitedHealthcare Medicaid	$18.09
Rate for Payer: UnitedHealthcare Medicare	$12.66
Rate for Payer: University Health Alliance Commercial	$21.98

CELLULITIS WITH MCC

Facility

$23,986.42

Service Code	MSDRG 602
Min. Negotiated Rate	$23,986.42
Max. Negotiated Rate	$23,986.42
Rate for Payer: Hawaii Medical Service Association Commercial	$23,986.42

CELLULITIS WITHOUT MCC

Facility

$16,141.06

Service Code	MSDRG 603
Min. Negotiated Rate	$16,141.06
Max. Negotiated Rate	$16,141.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16,141.06

CENTRAL DUAL ENERGY ABSORPTIOMETRY DOCD

Professional

Both

$0.01

Service Code	HCPCS 3095F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

CENTRAL LINE DRESSING KIT

Facility

$23.00

Hospital Charge Code	8056
Hospital Revenue Code	270
Min. Negotiated Rate	$9.66
Max. Negotiated Rate	$22.31
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$9.66
Rate for Payer: Cash Price	$14.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.16
Rate for Payer: Devoted Health Medicare	$9.66
Rate for Payer: Hawaii Medical Service Association Medicare	$9.66
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$9.66
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$9.66
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$9.66
Rate for Payer: Ohana Health Plan Medicare	$9.66
Rate for Payer: UnitedHealthcare Medicare	$9.66
Rate for Payer: University Health Alliance Commercial	$16.76

CENTRAL LINE DRESSING KIT

Facility

$23.00

Hospital Charge Code	8056
Hospital Revenue Code	270
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

CENTRAL LINE PLACEMENT

Facility

$3,255.00

Service Code	HCPCS 36556
Hospital Charge Code	317365560
Hospital Revenue Code	361
Min. Negotiated Rate	$2,766.75
Max. Negotiated Rate	$3,157.35
Rate for Payer: Cash Price	$2,115.75
Rate for Payer: Health Management Network Commercial	$2,766.75
Rate for Payer: Kaiser Permanente Commercial	$2,929.50
Rate for Payer: MDX Hawaii PPO	$3,157.35

CENTRAL LINE PLACEMENT

Facility

$3,255.00

Service Code	HCPCS 36556
Hospital Charge Code	317365560
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,662.59
Rate for Payer: AlohaCare Medicaid	$1,627.50
Rate for Payer: AlohaCare Medicare	$1,367.10
Rate for Payer: Cash Price	$2,115.75
Rate for Payer: Cash Price	$2,115.75
Rate for Payer: Cash Price	$2,115.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,994.60
Rate for Payer: Devoted Health Medicare	$1,367.10
Rate for Payer: Hawaii Medical Service Association Commercial	$4,662.59
Rate for Payer: Hawaii Medical Service Association Medicare	$1,367.10
Rate for Payer: Health Management Network Commercial	$2,766.75
Rate for Payer: Humana Medicare	$1,367.10
Rate for Payer: Kaiser Permanente Commercial	$2,929.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,367.10
Rate for Payer: MDX Hawaii PPO	$3,157.35
Rate for Payer: Ohana Health Plan Medicaid	$1,367.10
Rate for Payer: Ohana Health Plan Medicare	$1,367.10
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,367.10
Rate for Payer: University Health Alliance Commercial	$2,372.57

CENTRAL VEN CATH UNDER 5 Charge

Facility

$4,339.00

Service Code	HCPCS 36555
Hospital Charge Code	440365550
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,208.83
Rate for Payer: AlohaCare Medicaid	$2,169.50
Rate for Payer: AlohaCare Medicare	$1,822.38
Rate for Payer: Cash Price	$2,820.35
Rate for Payer: Cash Price	$2,820.35
Rate for Payer: Cash Price	$2,820.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3,991.88
Rate for Payer: Devoted Health Medicare	$1,822.38
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,822.38
Rate for Payer: Hawaii Western Management Group Commercial	$4,122.05
Rate for Payer: Health Management Network Commercial	$3,688.15
Rate for Payer: Humana Medicare	$1,822.38
Rate for Payer: Kaiser Permanente Commercial	$3,905.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,822.38
Rate for Payer: MDX Hawaii PPO	$4,208.83
Rate for Payer: Ohana Health Plan Medicaid	$1,822.38
Rate for Payer: Ohana Health Plan Medicare	$1,822.38
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,822.38
Rate for Payer: University Health Alliance Commercial	$3,162.70

Know your out-of-pocket cost for care.

All Charges