Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

cycloSPORINE ophthalmic 0.05% Emu UD [KMC]

Facility

$49.07

Service Code	NDC 60505620201
Hospital Revenue Code	250
Min. Negotiated Rate	$41.71
Max. Negotiated Rate	$47.60
Rate for Payer: Cash Price	$31.90
Rate for Payer: Health Management Network Commercial	$41.71
Rate for Payer: Kaiser Permanente Commercial	$44.16
Rate for Payer: MDX Hawaii PPO	$47.60

Cytopath, Thinprep and Manual

Facility

$100.00

Service Code	HCPCS 88142
Hospital Charge Code	422881425
Hospital Revenue Code	311
Min. Negotiated Rate	$20.26
Max. Negotiated Rate	$97.00
Rate for Payer: AlohaCare Medicaid	$50.00
Rate for Payer: AlohaCare Medicare	$42.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.00
Rate for Payer: Devoted Health Medicare	$42.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$28.00
Rate for Payer: Hawaii Medical Service Association Commercial	$25.32
Rate for Payer: Hawaii Medical Service Association Medicare	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$20.26
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: Kaiser Permanente Medicaid	$51.00
Rate for Payer: Kaiser Permanente Medicare	$42.00
Rate for Payer: MDX Hawaii PPO	$97.00
Rate for Payer: Ohana Health Plan Medicaid	$42.00
Rate for Payer: Ohana Health Plan Medicare	$42.00
Rate for Payer: UnitedHealthcare Medicaid	$28.00
Rate for Payer: UnitedHealthcare Medicare	$42.00
Rate for Payer: University Health Alliance Commercial	$52.37

Cytopath, Thinprep and Manual

Facility

$100.00

Service Code	HCPCS 88142
Hospital Charge Code	422881425
Hospital Revenue Code	311
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: MDX Hawaii PPO	$97.00

Cytopath, Thinprep, Manual Screen

Facility

$100.00

Service Code	HCPCS 88143
Hospital Charge Code	422881435
Hospital Revenue Code	311
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$97.00
Rate for Payer: AlohaCare Medicaid	$50.00
Rate for Payer: AlohaCare Medicare	$42.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.00
Rate for Payer: Devoted Health Medicare	$42.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.99
Rate for Payer: Hawaii Medical Service Association Commercial	$28.80
Rate for Payer: Hawaii Medical Service Association Medicare	$42.00
Rate for Payer: Hawaii Western Management Group Commercial	$23.04
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Humana Medicare	$42.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: Kaiser Permanente Medicaid	$51.00
Rate for Payer: Kaiser Permanente Medicare	$42.00
Rate for Payer: MDX Hawaii PPO	$97.00
Rate for Payer: Ohana Health Plan Medicaid	$42.00
Rate for Payer: Ohana Health Plan Medicare	$42.00
Rate for Payer: UnitedHealthcare Medicaid	$16.99
Rate for Payer: UnitedHealthcare Medicare	$42.00
Rate for Payer: University Health Alliance Commercial	$52.37

Cytopath, Thinprep, Manual Screen

Facility

$100.00

Service Code	HCPCS 88143
Hospital Charge Code	422881435
Hospital Revenue Code	311
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$90.00
Rate for Payer: MDX Hawaii PPO	$97.00

dabigatran 150 mg Cap [KMC]

Facility

$15.08

Service Code	NDC 43598064160
Hospital Revenue Code	250
Min. Negotiated Rate	$12.82
Max. Negotiated Rate	$14.63
Rate for Payer: Cash Price	$9.80
Rate for Payer: Health Management Network Commercial	$12.82
Rate for Payer: Kaiser Permanente Commercial	$13.57
Rate for Payer: MDX Hawaii PPO	$14.63

dabigatran 150 mg Cap [KMC]

Facility

$15.08

Service Code	NDC 43598064160
Hospital Revenue Code	250
Min. Negotiated Rate	$6.33
Max. Negotiated Rate	$14.63
Rate for Payer: AlohaCare Medicaid	$7.54
Rate for Payer: AlohaCare Medicare	$6.33
Rate for Payer: Cash Price	$9.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.87
Rate for Payer: Devoted Health Medicare	$6.33
Rate for Payer: Hawaii Medical Service Association Medicare	$6.33
Rate for Payer: Hawaii Western Management Group Commercial	$14.33
Rate for Payer: Health Management Network Commercial	$12.82
Rate for Payer: Humana Medicare	$6.33
Rate for Payer: Kaiser Permanente Commercial	$13.57
Rate for Payer: Kaiser Permanente Medicaid	$7.69
Rate for Payer: Kaiser Permanente Medicare	$6.33
Rate for Payer: MDX Hawaii PPO	$14.63
Rate for Payer: Ohana Health Plan Medicaid	$6.33
Rate for Payer: Ohana Health Plan Medicare	$6.33
Rate for Payer: UnitedHealthcare Medicaid	$9.05
Rate for Payer: UnitedHealthcare Medicare	$6.33
Rate for Payer: University Health Alliance Commercial	$10.99

dabigatran 75 mg Cap [KMC]

Facility

$26.20

Service Code	NDC 00597014954
Hospital Revenue Code	250
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$25.41
Rate for Payer: AlohaCare Medicaid	$13.10
Rate for Payer: AlohaCare Medicare	$11.00
Rate for Payer: Cash Price	$17.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$24.10
Rate for Payer: Devoted Health Medicare	$11.00
Rate for Payer: Hawaii Medical Service Association Medicare	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$24.89
Rate for Payer: Health Management Network Commercial	$22.27
Rate for Payer: Humana Medicare	$11.00
Rate for Payer: Kaiser Permanente Commercial	$23.58
Rate for Payer: Kaiser Permanente Medicaid	$13.36
Rate for Payer: Kaiser Permanente Medicare	$11.00
Rate for Payer: MDX Hawaii PPO	$25.41
Rate for Payer: Ohana Health Plan Medicaid	$11.00
Rate for Payer: Ohana Health Plan Medicare	$11.00
Rate for Payer: UnitedHealthcare Medicaid	$15.72
Rate for Payer: UnitedHealthcare Medicare	$11.00
Rate for Payer: University Health Alliance Commercial	$19.10

dabigatran 75 mg Cap [KMC]

Facility

$26.20

Service Code	NDC 00597014954
Hospital Revenue Code	250
Min. Negotiated Rate	$22.27
Max. Negotiated Rate	$25.41
Rate for Payer: Cash Price	$17.03
Rate for Payer: Health Management Network Commercial	$22.27
Rate for Payer: Kaiser Permanente Commercial	$23.58
Rate for Payer: MDX Hawaii PPO	$25.41

dabrafenib 75 mg Cap [KMC]

Facility

$417.09

Service Code	NDC 00078068166
Hospital Revenue Code	250
Min. Negotiated Rate	$354.53
Max. Negotiated Rate	$404.58
Rate for Payer: Cash Price	$271.11
Rate for Payer: Health Management Network Commercial	$354.53
Rate for Payer: Kaiser Permanente Commercial	$375.38
Rate for Payer: MDX Hawaii PPO	$404.58

dabrafenib 75 mg Cap [KMC]

Facility

$417.09

Service Code	NDC 00078068166
Hospital Revenue Code	250
Min. Negotiated Rate	$175.18
Max. Negotiated Rate	$404.58
Rate for Payer: AlohaCare Medicaid	$208.54
Rate for Payer: AlohaCare Medicare	$175.18
Rate for Payer: Cash Price	$271.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$383.72
Rate for Payer: Devoted Health Medicare	$175.18
Rate for Payer: Hawaii Medical Service Association Medicare	$175.18
Rate for Payer: Hawaii Western Management Group Commercial	$396.24
Rate for Payer: Health Management Network Commercial	$354.53
Rate for Payer: Humana Medicare	$175.18
Rate for Payer: Kaiser Permanente Commercial	$375.38
Rate for Payer: Kaiser Permanente Medicaid	$212.72
Rate for Payer: Kaiser Permanente Medicare	$175.18
Rate for Payer: MDX Hawaii PPO	$404.58
Rate for Payer: Ohana Health Plan Medicaid	$175.18
Rate for Payer: Ohana Health Plan Medicare	$175.18
Rate for Payer: UnitedHealthcare Medicaid	$250.25
Rate for Payer: UnitedHealthcare Medicare	$175.18
Rate for Payer: University Health Alliance Commercial	$304.02

dalbavancin 500 mg REC vial [KMC]

Facility

$8,539.82

Service Code	HCPCS J0875
Hospital Revenue Code	636
Min. Negotiated Rate	$7,258.85
Max. Negotiated Rate	$8,283.63
Rate for Payer: Cash Price	$5,550.88
Rate for Payer: Health Management Network Commercial	$7,258.85
Rate for Payer: Kaiser Permanente Commercial	$7,685.84
Rate for Payer: MDX Hawaii PPO	$8,283.63

dalbavancin 500 mg REC vial [KMC]

Facility

$8,539.82

Service Code	HCPCS J0875
Hospital Revenue Code	636
Min. Negotiated Rate	$15.55
Max. Negotiated Rate	$8,283.63
Rate for Payer: AlohaCare Medicaid	$4,269.91
Rate for Payer: AlohaCare Medicare	$3,586.72
Rate for Payer: Cash Price	$5,550.88
Rate for Payer: Cash Price	$5,550.88
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7,856.63
Rate for Payer: Devoted Health Medicare	$3,586.72
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$15.55
Rate for Payer: Hawaii Medical Service Association Commercial	$18.75
Rate for Payer: Hawaii Medical Service Association Medicare	$3,586.72
Rate for Payer: Hawaii Western Management Group Commercial	$8,112.83
Rate for Payer: Health Management Network Commercial	$7,258.85
Rate for Payer: Humana Medicare	$3,586.72
Rate for Payer: Kaiser Permanente Commercial	$7,685.84
Rate for Payer: Kaiser Permanente Medicaid	$4,355.31
Rate for Payer: Kaiser Permanente Medicare	$3,586.72
Rate for Payer: MDX Hawaii PPO	$8,283.63
Rate for Payer: Ohana Health Plan Medicaid	$3,586.72
Rate for Payer: Ohana Health Plan Medicare	$3,586.72
Rate for Payer: UnitedHealthcare Medicaid	$5,123.89
Rate for Payer: UnitedHealthcare Medicare	$3,586.72
Rate for Payer: University Health Alliance Commercial	$6,224.67

dalfampridine 10 mg ER tablet [KMC]

Facility

$189.50

Service Code	NDC 67877044460
Hospital Revenue Code	250
Min. Negotiated Rate	$79.59
Max. Negotiated Rate	$183.81
Rate for Payer: AlohaCare Medicaid	$94.75
Rate for Payer: AlohaCare Medicare	$79.59
Rate for Payer: Cash Price	$123.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$174.34
Rate for Payer: Devoted Health Medicare	$79.59
Rate for Payer: Hawaii Medical Service Association Medicare	$79.59
Rate for Payer: Hawaii Western Management Group Commercial	$180.03
Rate for Payer: Health Management Network Commercial	$161.07
Rate for Payer: Humana Medicare	$79.59
Rate for Payer: Kaiser Permanente Commercial	$170.55
Rate for Payer: Kaiser Permanente Medicaid	$96.64
Rate for Payer: Kaiser Permanente Medicare	$79.59
Rate for Payer: MDX Hawaii PPO	$183.81
Rate for Payer: Ohana Health Plan Medicaid	$79.59
Rate for Payer: Ohana Health Plan Medicare	$79.59
Rate for Payer: UnitedHealthcare Medicaid	$113.70
Rate for Payer: UnitedHealthcare Medicare	$79.59
Rate for Payer: University Health Alliance Commercial	$138.13

dalfampridine 10 mg ER tablet [KMC]

Facility

$189.50

Service Code	NDC 67877044460
Hospital Revenue Code	250
Min. Negotiated Rate	$161.07
Max. Negotiated Rate	$183.81
Rate for Payer: Cash Price	$123.18
Rate for Payer: Health Management Network Commercial	$161.07
Rate for Payer: Kaiser Permanente Commercial	$170.55
Rate for Payer: MDX Hawaii PPO	$183.81

dantrolene 20 mg IV Inj [KMC]

Facility

$425.47

Service Code	NDC 42023012306
Hospital Revenue Code	250
Min. Negotiated Rate	$361.65
Max. Negotiated Rate	$412.71
Rate for Payer: Cash Price	$276.56
Rate for Payer: Health Management Network Commercial	$361.65
Rate for Payer: Kaiser Permanente Commercial	$382.92
Rate for Payer: MDX Hawaii PPO	$412.71

dantrolene 20 mg IV Inj [KMC]

Facility

$425.47

Service Code	NDC 42023012306
Hospital Revenue Code	250
Min. Negotiated Rate	$178.70
Max. Negotiated Rate	$412.71
Rate for Payer: AlohaCare Medicaid	$212.74
Rate for Payer: AlohaCare Medicare	$178.70
Rate for Payer: Cash Price	$276.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$391.43
Rate for Payer: Devoted Health Medicare	$178.70
Rate for Payer: Hawaii Medical Service Association Medicare	$178.70
Rate for Payer: Hawaii Western Management Group Commercial	$404.20
Rate for Payer: Health Management Network Commercial	$361.65
Rate for Payer: Humana Medicare	$178.70
Rate for Payer: Kaiser Permanente Commercial	$382.92
Rate for Payer: Kaiser Permanente Medicaid	$216.99
Rate for Payer: Kaiser Permanente Medicare	$178.70
Rate for Payer: MDX Hawaii PPO	$412.71
Rate for Payer: Ohana Health Plan Medicaid	$178.70
Rate for Payer: Ohana Health Plan Medicare	$178.70
Rate for Payer: UnitedHealthcare Medicaid	$255.28
Rate for Payer: UnitedHealthcare Medicare	$178.70
Rate for Payer: University Health Alliance Commercial	$310.13

dantrolene 250 mg vial [KMC]

Facility

$14,040.84

Service Code	NDC 42367054032
Hospital Revenue Code	250
Min. Negotiated Rate	$5,897.15
Max. Negotiated Rate	$13,619.61
Rate for Payer: AlohaCare Medicaid	$7,020.42
Rate for Payer: AlohaCare Medicare	$5,897.15
Rate for Payer: Cash Price	$9,126.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12,917.57
Rate for Payer: Devoted Health Medicare	$5,897.15
Rate for Payer: Hawaii Medical Service Association Medicare	$5,897.15
Rate for Payer: Hawaii Western Management Group Commercial	$13,338.80
Rate for Payer: Health Management Network Commercial	$11,934.71
Rate for Payer: Humana Medicare	$5,897.15
Rate for Payer: Kaiser Permanente Commercial	$12,636.76
Rate for Payer: Kaiser Permanente Medicaid	$7,160.83
Rate for Payer: Kaiser Permanente Medicare	$5,897.15
Rate for Payer: MDX Hawaii PPO	$13,619.61
Rate for Payer: Ohana Health Plan Medicaid	$5,897.15
Rate for Payer: Ohana Health Plan Medicare	$5,897.15
Rate for Payer: UnitedHealthcare Medicaid	$8,424.50
Rate for Payer: UnitedHealthcare Medicare	$5,897.15
Rate for Payer: University Health Alliance Commercial	$10,234.37

dantrolene 250 mg vial [KMC]

Facility

$14,040.84

Service Code	NDC 42367054032
Hospital Revenue Code	250
Min. Negotiated Rate	$11,934.71
Max. Negotiated Rate	$13,619.61
Rate for Payer: Cash Price	$9,126.55
Rate for Payer: Health Management Network Commercial	$11,934.71
Rate for Payer: Kaiser Permanente Commercial	$12,636.76
Rate for Payer: MDX Hawaii PPO	$13,619.61

dapagliflozin 10 mg Tab [KMC]

Facility

$88.50

Service Code	NDC 66993045730
Hospital Revenue Code	250
Min. Negotiated Rate	$75.22
Max. Negotiated Rate	$85.84
Rate for Payer: Cash Price	$57.52
Rate for Payer: Health Management Network Commercial	$75.22
Rate for Payer: Kaiser Permanente Commercial	$79.65
Rate for Payer: MDX Hawaii PPO	$85.84

dapagliflozin 10 mg Tab [KMC]

Facility

$88.50

Service Code	NDC 66993045730
Hospital Revenue Code	250
Min. Negotiated Rate	$37.17
Max. Negotiated Rate	$85.84
Rate for Payer: AlohaCare Medicaid	$44.25
Rate for Payer: AlohaCare Medicare	$37.17
Rate for Payer: Cash Price	$57.52
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$81.42
Rate for Payer: Devoted Health Medicare	$37.17
Rate for Payer: Hawaii Medical Service Association Medicare	$37.17
Rate for Payer: Hawaii Western Management Group Commercial	$84.08
Rate for Payer: Health Management Network Commercial	$75.22
Rate for Payer: Humana Medicare	$37.17
Rate for Payer: Kaiser Permanente Commercial	$79.65
Rate for Payer: Kaiser Permanente Medicaid	$45.13
Rate for Payer: Kaiser Permanente Medicare	$37.17
Rate for Payer: MDX Hawaii PPO	$85.84
Rate for Payer: Ohana Health Plan Medicaid	$37.17
Rate for Payer: Ohana Health Plan Medicare	$37.17
Rate for Payer: UnitedHealthcare Medicaid	$53.10
Rate for Payer: UnitedHealthcare Medicare	$37.17
Rate for Payer: University Health Alliance Commercial	$64.51

dapsone 100 mg Tab [KMC]

Facility

$12.09

Service Code	NDC 70954013610
Hospital Revenue Code	250
Min. Negotiated Rate	$10.28
Max. Negotiated Rate	$11.73
Rate for Payer: Cash Price	$7.86
Rate for Payer: Health Management Network Commercial	$10.28
Rate for Payer: Kaiser Permanente Commercial	$10.88
Rate for Payer: MDX Hawaii PPO	$11.73

dapsone 100 mg Tab [KMC]

Facility

$12.09

Service Code	NDC 70954013610
Hospital Revenue Code	250
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$11.73
Rate for Payer: AlohaCare Medicaid	$6.04
Rate for Payer: AlohaCare Medicare	$5.08
Rate for Payer: Cash Price	$7.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.12
Rate for Payer: Devoted Health Medicare	$5.08
Rate for Payer: Hawaii Medical Service Association Medicare	$5.08
Rate for Payer: Hawaii Western Management Group Commercial	$11.49
Rate for Payer: Health Management Network Commercial	$10.28
Rate for Payer: Humana Medicare	$5.08
Rate for Payer: Kaiser Permanente Commercial	$10.88
Rate for Payer: Kaiser Permanente Medicaid	$6.17
Rate for Payer: Kaiser Permanente Medicare	$5.08
Rate for Payer: MDX Hawaii PPO	$11.73
Rate for Payer: Ohana Health Plan Medicaid	$5.08
Rate for Payer: Ohana Health Plan Medicare	$5.08
Rate for Payer: UnitedHealthcare Medicaid	$7.25
Rate for Payer: UnitedHealthcare Medicare	$5.08
Rate for Payer: University Health Alliance Commercial	$8.81

dapsone 25 mg Tab [KMC]

Facility

$9.46

Service Code	NDC 70954013510
Hospital Revenue Code	250
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$9.18
Rate for Payer: AlohaCare Medicaid	$4.73
Rate for Payer: AlohaCare Medicare	$3.97
Rate for Payer: Cash Price	$6.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.70
Rate for Payer: Devoted Health Medicare	$3.97
Rate for Payer: Hawaii Medical Service Association Medicare	$3.97
Rate for Payer: Hawaii Western Management Group Commercial	$8.99
Rate for Payer: Health Management Network Commercial	$8.04
Rate for Payer: Humana Medicare	$3.97
Rate for Payer: Kaiser Permanente Commercial	$8.51
Rate for Payer: Kaiser Permanente Medicaid	$4.82
Rate for Payer: Kaiser Permanente Medicare	$3.97
Rate for Payer: MDX Hawaii PPO	$9.18
Rate for Payer: Ohana Health Plan Medicaid	$3.97
Rate for Payer: Ohana Health Plan Medicare	$3.97
Rate for Payer: UnitedHealthcare Medicaid	$5.68
Rate for Payer: UnitedHealthcare Medicare	$3.97
Rate for Payer: University Health Alliance Commercial	$6.90

dapsone 25 mg Tab [KMC]

Facility

$9.46

Service Code	NDC 70954013510
Hospital Revenue Code	250
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$9.18
Rate for Payer: Cash Price	$6.15
Rate for Payer: Health Management Network Commercial	$8.04
Rate for Payer: Kaiser Permanente Commercial	$8.51
Rate for Payer: MDX Hawaii PPO	$9.18

Know your out-of-pocket cost for care.

All Charges