Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

CHLORAHEXIDINE 2% GLUCONATE CLOTH

Facility

$2.00

Hospital Charge Code	8565
Hospital Revenue Code	270
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

chlordiazePOXIDE 10 mg Cap [KMC)

Facility

$3.00

Service Code	NDC 00555003302
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

chlordiazePOXIDE 10 mg Cap [KMC)

Facility

$3.00

Service Code	NDC 00555003302
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

chlordiazePOXIDE 25 mg Cap [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

chlordiazePOXIDE 25 mg Cap [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

chlordiazePOXIDE 5 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 00555015802
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

chlordiazePOXIDE 5 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 00555015802
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

chlorhexidine 0.12% Oral Rinse Liquid [KMC]

Facility

$0.09

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.08
Rate for Payer: Kaiser Permanente Commercial	$0.08
Rate for Payer: MDX Hawaii PPO	$0.09

chlorhexidine 0.12% Oral Rinse Liquid [KMC]

Facility

$0.09

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.09
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	$0.08
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	$0.09
Rate for Payer: Health Management Network Commercial	$0.08
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.08
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.09
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

chlorhexidine Top 4% Soap [KMC]

Facility

$0.12

Service Code	NDC 67618020008
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.12
Rate for Payer: AlohaCare Medicaid	$0.06
Rate for Payer: AlohaCare Medicare	$0.05
Rate for Payer: Cash Price	$0.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.11
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Hawaii Medical Service Association Medicare	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$0.11
Rate for Payer: Health Management Network Commercial	$0.10
Rate for Payer: Humana Medicare	$0.05
Rate for Payer: Kaiser Permanente Commercial	$0.11
Rate for Payer: Kaiser Permanente Medicaid	$0.06
Rate for Payer: Kaiser Permanente Medicare	$0.05
Rate for Payer: MDX Hawaii PPO	$0.12
Rate for Payer: Ohana Health Plan Medicaid	$0.05
Rate for Payer: Ohana Health Plan Medicare	$0.05
Rate for Payer: UnitedHealthcare Medicaid	$0.07
Rate for Payer: UnitedHealthcare Medicare	$0.05
Rate for Payer: University Health Alliance Commercial	$0.09

chlorhexidine Top 4% Soap [KMC]

Facility

$0.12

Service Code	NDC 67618020008
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Management Network Commercial	$0.10
Rate for Payer: Kaiser Permanente Commercial	$0.11
Rate for Payer: MDX Hawaii PPO	$0.12

Chloride DLS

Facility

$109.00

Service Code	HCPCS 82435
Hospital Charge Code	422824355
Hospital Revenue Code	301
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$45.78
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$100.28
Rate for Payer: Devoted Health Medicare	$45.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.35
Rate for Payer: Hawaii Medical Service Association Commercial	$5.75
Rate for Payer: Hawaii Medical Service Association Medicare	$45.78
Rate for Payer: Hawaii Western Management Group Commercial	$4.60
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$45.78
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$45.78
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$45.78
Rate for Payer: Ohana Health Plan Medicare	$45.78
Rate for Payer: UnitedHealthcare Medicaid	$6.35
Rate for Payer: UnitedHealthcare Medicare	$45.78
Rate for Payer: University Health Alliance Commercial	$11.88

Chloride DLS

Facility

$109.00

Service Code	HCPCS 82435
Hospital Charge Code	422824355
Hospital Revenue Code	301
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

Chloride Level

Facility

$109.00

Service Code	HCPCS 82435
Hospital Charge Code	422824350
Hospital Revenue Code	301
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$45.78
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$100.28
Rate for Payer: Devoted Health Medicare	$45.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.35
Rate for Payer: Hawaii Medical Service Association Commercial	$5.75
Rate for Payer: Hawaii Medical Service Association Medicare	$45.78
Rate for Payer: Hawaii Western Management Group Commercial	$4.60
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$45.78
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$45.78
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$45.78
Rate for Payer: Ohana Health Plan Medicare	$45.78
Rate for Payer: UnitedHealthcare Medicaid	$6.35
Rate for Payer: UnitedHealthcare Medicare	$45.78
Rate for Payer: University Health Alliance Commercial	$11.88

Chloride Level

Facility

$109.00

Service Code	HCPCS 82435
Hospital Charge Code	422824350
Hospital Revenue Code	301
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

chlorproMAZINE 50 mg Tab [KMC]

Facility

$41.50

Service Code	HCPCS Q0161
Hospital Revenue Code	637
Min. Negotiated Rate	$17.43
Max. Negotiated Rate	$40.26
Rate for Payer: AlohaCare Medicaid	$20.75
Rate for Payer: AlohaCare Medicare	$17.43
Rate for Payer: Cash Price	$26.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$38.18
Rate for Payer: Devoted Health Medicare	$17.43
Rate for Payer: Hawaii Medical Service Association Medicare	$17.43
Rate for Payer: Hawaii Western Management Group Commercial	$39.42
Rate for Payer: Health Management Network Commercial	$35.27
Rate for Payer: Humana Medicare	$17.43
Rate for Payer: Kaiser Permanente Commercial	$37.35
Rate for Payer: Kaiser Permanente Medicaid	$21.16
Rate for Payer: Kaiser Permanente Medicare	$17.43
Rate for Payer: MDX Hawaii PPO	$40.26
Rate for Payer: Ohana Health Plan Medicaid	$17.43
Rate for Payer: Ohana Health Plan Medicare	$17.43
Rate for Payer: UnitedHealthcare Medicare	$17.43
Rate for Payer: University Health Alliance Commercial	$30.25

chlorproMAZINE 50 mg Tab [KMC]

Facility

$41.50

Service Code	HCPCS Q0161
Hospital Revenue Code	637
Min. Negotiated Rate	$35.27
Max. Negotiated Rate	$40.26
Rate for Payer: Cash Price	$26.98
Rate for Payer: Health Management Network Commercial	$35.27
Rate for Payer: Kaiser Permanente Commercial	$37.35
Rate for Payer: MDX Hawaii PPO	$40.26

chlorthalidone 25 mg Tab [KMC]

Facility

$4.83

Service Code	NDC 43598017001
Hospital Revenue Code	250
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$4.69
Rate for Payer: Cash Price	$3.14
Rate for Payer: Health Management Network Commercial	$4.11
Rate for Payer: Kaiser Permanente Commercial	$4.35
Rate for Payer: MDX Hawaii PPO	$4.69

chlorthalidone 25 mg Tab [KMC]

Facility

$4.83

Service Code	NDC 43598017001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$4.69
Rate for Payer: AlohaCare Medicaid	$2.42
Rate for Payer: AlohaCare Medicare	$2.03
Rate for Payer: Cash Price	$3.14
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.44
Rate for Payer: Devoted Health Medicare	$2.03
Rate for Payer: Hawaii Medical Service Association Medicare	$2.03
Rate for Payer: Hawaii Western Management Group Commercial	$4.59
Rate for Payer: Health Management Network Commercial	$4.11
Rate for Payer: Humana Medicare	$2.03
Rate for Payer: Kaiser Permanente Commercial	$4.35
Rate for Payer: Kaiser Permanente Medicaid	$2.46
Rate for Payer: Kaiser Permanente Medicare	$2.03
Rate for Payer: MDX Hawaii PPO	$4.69
Rate for Payer: Ohana Health Plan Medicaid	$2.03
Rate for Payer: Ohana Health Plan Medicare	$2.03
Rate for Payer: UnitedHealthcare Medicaid	$2.90
Rate for Payer: UnitedHealthcare Medicare	$2.03
Rate for Payer: University Health Alliance Commercial	$3.52

chlorzoxazone 500 mg Tab [KMC]

Facility

$4.40

Service Code	NDC 70954008510
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$4.27
Rate for Payer: AlohaCare Medicaid	$2.20
Rate for Payer: AlohaCare Medicare	$1.85
Rate for Payer: Cash Price	$2.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.05
Rate for Payer: Devoted Health Medicare	$1.85
Rate for Payer: Hawaii Medical Service Association Medicare	$1.85
Rate for Payer: Hawaii Western Management Group Commercial	$4.18
Rate for Payer: Health Management Network Commercial	$3.74
Rate for Payer: Humana Medicare	$1.85
Rate for Payer: Kaiser Permanente Commercial	$3.96
Rate for Payer: Kaiser Permanente Medicaid	$2.24
Rate for Payer: Kaiser Permanente Medicare	$1.85
Rate for Payer: MDX Hawaii PPO	$4.27
Rate for Payer: Ohana Health Plan Medicaid	$1.85
Rate for Payer: Ohana Health Plan Medicare	$1.85
Rate for Payer: UnitedHealthcare Medicaid	$2.64
Rate for Payer: UnitedHealthcare Medicare	$1.85
Rate for Payer: University Health Alliance Commercial	$3.21

chlorzoxazone 500 mg Tab [KMC]

Facility

$4.40

Service Code	NDC 70954008510
Hospital Revenue Code	250
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$4.27
Rate for Payer: Cash Price	$2.86
Rate for Payer: Health Management Network Commercial	$3.74
Rate for Payer: Kaiser Permanente Commercial	$3.96
Rate for Payer: MDX Hawaii PPO	$4.27

cholecalciferol 1000 units tablet [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

cholecalciferol 1000 units tablet [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

cholecalciferol 50,000 units (1,250 mcg) Cap [KMC]

Facility

$3.00

Service Code	NDC 80681017400
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

cholecalciferol 50,000 units (1,250 mcg) Cap [KMC]

Facility

$3.00

Service Code	NDC 80681017400
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

Know your out-of-pocket cost for care.

All Charges