Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

cilostazol 100 mg Tab [KMC]

Facility

$7.30

Service Code	NDC 00093206406
Hospital Revenue Code	250
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$7.08
Rate for Payer: AlohaCare Medicaid	$3.65
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$4.74
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.72
Rate for Payer: Devoted Health Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Western Management Group Commercial	$6.93
Rate for Payer: Health Management Network Commercial	$6.21
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$6.57
Rate for Payer: Kaiser Permanente Medicaid	$3.72
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$7.08
Rate for Payer: Ohana Health Plan Medicaid	$3.07
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$4.38
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$5.32

cimetidine 300 mg Tab [KMC]

Facility

$8.21

Service Code	NDC 00093819201
Hospital Revenue Code	250
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$7.96
Rate for Payer: Cash Price	$5.34
Rate for Payer: Health Management Network Commercial	$6.98
Rate for Payer: Kaiser Permanente Commercial	$7.39
Rate for Payer: MDX Hawaii PPO	$7.96

cimetidine 300 mg Tab [KMC]

Facility

$8.21

Service Code	NDC 00093819201
Hospital Revenue Code	250
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$7.96
Rate for Payer: AlohaCare Medicaid	$4.11
Rate for Payer: AlohaCare Medicare	$3.45
Rate for Payer: Cash Price	$5.34
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.55
Rate for Payer: Devoted Health Medicare	$3.45
Rate for Payer: Hawaii Medical Service Association Medicare	$3.45
Rate for Payer: Hawaii Western Management Group Commercial	$7.80
Rate for Payer: Health Management Network Commercial	$6.98
Rate for Payer: Humana Medicare	$3.45
Rate for Payer: Kaiser Permanente Commercial	$7.39
Rate for Payer: Kaiser Permanente Medicaid	$4.19
Rate for Payer: Kaiser Permanente Medicare	$3.45
Rate for Payer: MDX Hawaii PPO	$7.96
Rate for Payer: Ohana Health Plan Medicaid	$3.45
Rate for Payer: Ohana Health Plan Medicare	$3.45
Rate for Payer: UnitedHealthcare Medicaid	$4.93
Rate for Payer: UnitedHealthcare Medicare	$3.45
Rate for Payer: University Health Alliance Commercial	$5.98

cinacalcet 30 mg Tab[KMC]

Facility

$129.07

Service Code	NDC 55513007330
Hospital Revenue Code	250
Min. Negotiated Rate	$109.71
Max. Negotiated Rate	$125.20
Rate for Payer: Cash Price	$83.90
Rate for Payer: Health Management Network Commercial	$109.71
Rate for Payer: Kaiser Permanente Commercial	$116.16
Rate for Payer: MDX Hawaii PPO	$125.20

cinacalcet 30 mg Tab[KMC]

Facility

$129.07

Service Code	NDC 55513007330
Hospital Revenue Code	250
Min. Negotiated Rate	$54.21
Max. Negotiated Rate	$125.20
Rate for Payer: AlohaCare Medicaid	$64.53
Rate for Payer: AlohaCare Medicare	$54.21
Rate for Payer: Cash Price	$83.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.74
Rate for Payer: Devoted Health Medicare	$54.21
Rate for Payer: Hawaii Medical Service Association Medicare	$54.21
Rate for Payer: Hawaii Western Management Group Commercial	$122.62
Rate for Payer: Health Management Network Commercial	$109.71
Rate for Payer: Humana Medicare	$54.21
Rate for Payer: Kaiser Permanente Commercial	$116.16
Rate for Payer: Kaiser Permanente Medicaid	$65.83
Rate for Payer: Kaiser Permanente Medicare	$54.21
Rate for Payer: MDX Hawaii PPO	$125.20
Rate for Payer: Ohana Health Plan Medicaid	$54.21
Rate for Payer: Ohana Health Plan Medicare	$54.21
Rate for Payer: UnitedHealthcare Medicaid	$77.44
Rate for Payer: UnitedHealthcare Medicare	$54.21
Rate for Payer: University Health Alliance Commercial	$94.08

cinacalcet 60 mg Tab [KMC]

Facility

$245.24

Service Code	HCPCS J0604
Hospital Revenue Code	636
Min. Negotiated Rate	$208.45
Max. Negotiated Rate	$237.88
Rate for Payer: Cash Price	$159.41
Rate for Payer: Health Management Network Commercial	$208.45
Rate for Payer: Kaiser Permanente Commercial	$220.72
Rate for Payer: MDX Hawaii PPO	$237.88

cinacalcet 60 mg Tab [KMC]

Facility

$245.24

Service Code	HCPCS J0604
Hospital Revenue Code	636
Min. Negotiated Rate	$103.00
Max. Negotiated Rate	$237.88
Rate for Payer: AlohaCare Medicaid	$122.62
Rate for Payer: AlohaCare Medicare	$103.00
Rate for Payer: Cash Price	$159.41
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$225.62
Rate for Payer: Devoted Health Medicare	$103.00
Rate for Payer: Hawaii Medical Service Association Medicare	$103.00
Rate for Payer: Hawaii Western Management Group Commercial	$232.98
Rate for Payer: Health Management Network Commercial	$208.45
Rate for Payer: Humana Medicare	$103.00
Rate for Payer: Kaiser Permanente Commercial	$220.72
Rate for Payer: Kaiser Permanente Medicaid	$125.07
Rate for Payer: Kaiser Permanente Medicare	$103.00
Rate for Payer: MDX Hawaii PPO	$237.88
Rate for Payer: Ohana Health Plan Medicaid	$103.00
Rate for Payer: Ohana Health Plan Medicare	$103.00
Rate for Payer: UnitedHealthcare Medicaid	$147.14
Rate for Payer: UnitedHealthcare Medicare	$103.00
Rate for Payer: University Health Alliance Commercial	$178.76

ciprofloxacin 400 mg/200 mL IV Sol [KMC]

Facility

$0.17

Service Code	HCPCS J0744
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Management Network Commercial	$0.14
Rate for Payer: Kaiser Permanente Commercial	$0.15
Rate for Payer: MDX Hawaii PPO	$0.16

ciprofloxacin 400 mg/200 mL IV Sol [KMC]

Facility

$0.17

Service Code	HCPCS J0744
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$2.32
Rate for Payer: AlohaCare Medicaid	$0.09
Rate for Payer: AlohaCare Medicare	$0.07
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.16
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.32
Rate for Payer: Hawaii Medical Service Association Medicare	$0.07
Rate for Payer: Hawaii Western Management Group Commercial	$0.16
Rate for Payer: Health Management Network Commercial	$0.14
Rate for Payer: Humana Medicare	$0.07
Rate for Payer: Kaiser Permanente Commercial	$0.15
Rate for Payer: Kaiser Permanente Medicaid	$0.09
Rate for Payer: Kaiser Permanente Medicare	$0.07
Rate for Payer: MDX Hawaii PPO	$0.16
Rate for Payer: Ohana Health Plan Medicaid	$0.07
Rate for Payer: Ohana Health Plan Medicare	$0.07
Rate for Payer: UnitedHealthcare Medicaid	$0.10
Rate for Payer: UnitedHealthcare Medicare	$0.07
Rate for Payer: University Health Alliance Commercial	$0.12

ciprofloxacin 500 mg 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

ciprofloxacin 500 mg 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

ciprofloxacin ophthalmic 0.3% Sol [KMC]

Facility

$40.05

Service Code	NDC 61314065625
Hospital Revenue Code	250
Min. Negotiated Rate	$16.82
Max. Negotiated Rate	$38.85
Rate for Payer: AlohaCare Medicaid	$20.02
Rate for Payer: AlohaCare Medicare	$16.82
Rate for Payer: Cash Price	$26.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$36.85
Rate for Payer: Devoted Health Medicare	$16.82
Rate for Payer: Hawaii Medical Service Association Medicare	$16.82
Rate for Payer: Hawaii Western Management Group Commercial	$38.05
Rate for Payer: Health Management Network Commercial	$34.04
Rate for Payer: Humana Medicare	$16.82
Rate for Payer: Kaiser Permanente Commercial	$36.05
Rate for Payer: Kaiser Permanente Medicaid	$20.43
Rate for Payer: Kaiser Permanente Medicare	$16.82
Rate for Payer: MDX Hawaii PPO	$38.85
Rate for Payer: Ohana Health Plan Medicaid	$16.82
Rate for Payer: Ohana Health Plan Medicare	$16.82
Rate for Payer: UnitedHealthcare Medicaid	$24.03
Rate for Payer: UnitedHealthcare Medicare	$16.82
Rate for Payer: University Health Alliance Commercial	$29.19

ciprofloxacin ophthalmic 0.3% Sol [KMC]

Facility

$40.05

Service Code	NDC 61314065625
Hospital Revenue Code	250
Min. Negotiated Rate	$34.04
Max. Negotiated Rate	$38.85
Rate for Payer: Cash Price	$26.03
Rate for Payer: Health Management Network Commercial	$34.04
Rate for Payer: Kaiser Permanente Commercial	$36.05
Rate for Payer: MDX Hawaii PPO	$38.85

CIRCUIT DEP W/FEB HOSE

Facility

$30.00

Hospital Charge Code	8447
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$29.10
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$19.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$27.60
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Humana Medicare	$12.60
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicare	$12.60
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: Ohana Health Plan Medicaid	$12.60
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicare	$12.60
Rate for Payer: University Health Alliance Commercial	$21.87

CIRCUIT DEP W/FEB HOSE

Facility

$30.00

Hospital Charge Code	8447
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$19.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: MDX Hawaii PPO	$29.10

CIRCUIT DEP W/ FEP LG

Facility

$113.00

Hospital Charge Code	8059
Hospital Revenue Code	270
Min. Negotiated Rate	$47.46
Max. Negotiated Rate	$109.61
Rate for Payer: AlohaCare Medicaid	$56.50
Rate for Payer: AlohaCare Medicare	$47.46
Rate for Payer: Cash Price	$73.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$103.96
Rate for Payer: Devoted Health Medicare	$47.46
Rate for Payer: Hawaii Medical Service Association Medicare	$47.46
Rate for Payer: Hawaii Western Management Group Commercial	$107.35
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Humana Medicare	$47.46
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: Kaiser Permanente Medicaid	$57.63
Rate for Payer: Kaiser Permanente Medicare	$47.46
Rate for Payer: MDX Hawaii PPO	$109.61
Rate for Payer: Ohana Health Plan Medicaid	$47.46
Rate for Payer: Ohana Health Plan Medicare	$47.46
Rate for Payer: UnitedHealthcare Medicare	$47.46
Rate for Payer: University Health Alliance Commercial	$82.37

CIRCUIT DEP W/ FEP LG

Facility

$113.00

Hospital Charge Code	8059
Hospital Revenue Code	270
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$73.45
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: MDX Hawaii PPO	$109.61

CIRCUIT DEP W/ FEP MED

Facility

$159.00

Hospital Charge Code	8060
Hospital Revenue Code	270
Min. Negotiated Rate	$135.15
Max. Negotiated Rate	$154.23
Rate for Payer: Cash Price	$103.35
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: MDX Hawaii PPO	$154.23

CIRCUIT DEP W/ FEP MED

Facility

$159.00

Hospital Charge Code	8060
Hospital Revenue Code	270
Min. Negotiated Rate	$66.78
Max. Negotiated Rate	$154.23
Rate for Payer: AlohaCare Medicaid	$79.50
Rate for Payer: AlohaCare Medicare	$66.78
Rate for Payer: Cash Price	$103.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$146.28
Rate for Payer: Devoted Health Medicare	$66.78
Rate for Payer: Hawaii Medical Service Association Medicare	$66.78
Rate for Payer: Hawaii Western Management Group Commercial	$151.05
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Humana Medicare	$66.78
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: Kaiser Permanente Medicaid	$81.09
Rate for Payer: Kaiser Permanente Medicare	$66.78
Rate for Payer: MDX Hawaii PPO	$154.23
Rate for Payer: Ohana Health Plan Medicaid	$66.78
Rate for Payer: Ohana Health Plan Medicare	$66.78
Rate for Payer: UnitedHealthcare Medicare	$66.78
Rate for Payer: University Health Alliance Commercial	$115.90

CIRCUIT DEP W/ FEP SM

Facility

$31.00

Hospital Charge Code	8061
Hospital Revenue Code	270
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$20.15
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

CIRCUIT DEP W/ FEP SM

Facility

$31.00

Hospital Charge Code	8061
Hospital Revenue Code	270
Min. Negotiated Rate	$13.02
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$13.02
Rate for Payer: Cash Price	$20.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$28.52
Rate for Payer: Devoted Health Medicare	$13.02
Rate for Payer: Hawaii Medical Service Association Medicare	$13.02
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$13.02
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$13.02
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$13.02
Rate for Payer: Ohana Health Plan Medicare	$13.02
Rate for Payer: UnitedHealthcare Medicare	$13.02
Rate for Payer: University Health Alliance Commercial	$22.60

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC

Facility

$34,130.88

Service Code	MSDRG 286
Min. Negotiated Rate	$34,130.88
Max. Negotiated Rate	$34,130.88
Rate for Payer: Hawaii Medical Service Association Commercial	$34,130.88

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$30,054.14

Service Code	MSDRG 287
Min. Negotiated Rate	$30,054.14
Max. Negotiated Rate	$30,054.14
Rate for Payer: Hawaii Medical Service Association Commercial	$30,054.14

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC

Facility

$41,336.29

Service Code	MSDRG 433
Min. Negotiated Rate	$41,336.29
Max. Negotiated Rate	$41,336.29
Rate for Payer: Hawaii Medical Service Association Commercial	$41,336.29

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC

Facility

$41,336.29

Service Code	MSDRG 432
Min. Negotiated Rate	$41,336.29
Max. Negotiated Rate	$41,336.29
Rate for Payer: Hawaii Medical Service Association Commercial	$41,336.29

Know your out-of-pocket cost for care.

All Charges