Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

dexAMETHasone 0.5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J8540
Hospital Revenue Code	636
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

dexAMETHasone 0.5 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS J8540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
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: 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 ABD/Non-ABD	$0.02
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

dexamethasone 10 mg/mL Inj Sol [KMC]

Facility

$6.86

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$5.83
Max. Negotiated Rate	$6.65
Rate for Payer: Cash Price	$4.46
Rate for Payer: Health Management Network Commercial	$5.83
Rate for Payer: Kaiser Permanente Commercial	$6.17
Rate for Payer: MDX Hawaii PPO	$6.65

dexamethasone 10 mg/mL Inj Sol [KMC]

Facility

$6.86

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$6.65
Rate for Payer: AlohaCare Medicaid	$3.43
Rate for Payer: AlohaCare Medicare	$2.88
Rate for Payer: Cash Price	$4.46
Rate for Payer: Cash Price	$4.46
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.31
Rate for Payer: Devoted Health Medicare	$2.88
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$2.88
Rate for Payer: Hawaii Western Management Group Commercial	$6.52
Rate for Payer: Health Management Network Commercial	$5.83
Rate for Payer: Humana Medicare	$2.88
Rate for Payer: Kaiser Permanente Commercial	$6.17
Rate for Payer: Kaiser Permanente Medicaid	$3.50
Rate for Payer: Kaiser Permanente Medicare	$2.88
Rate for Payer: MDX Hawaii PPO	$6.65
Rate for Payer: Ohana Health Plan Medicaid	$2.88
Rate for Payer: Ohana Health Plan Medicare	$2.88
Rate for Payer: UnitedHealthcare Medicaid	$4.12
Rate for Payer: UnitedHealthcare Medicare	$2.88
Rate for Payer: University Health Alliance Commercial	$5.00

dexamethasone 1 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 72578016601
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

dexamethasone 1 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 72578016601
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

dexamethasone 4 mg Tab [KMC]

Facility

$4.76

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.62
Rate for Payer: AlohaCare Medicaid	$2.38
Rate for Payer: AlohaCare Medicare	$2.00
Rate for Payer: Cash Price	$3.09
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.38
Rate for Payer: Devoted Health Medicare	$2.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2.00
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Humana Medicare	$2.00
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: Kaiser Permanente Medicaid	$2.43
Rate for Payer: Kaiser Permanente Medicare	$2.00
Rate for Payer: MDX Hawaii PPO	$4.62
Rate for Payer: Ohana Health Plan Medicaid	$2.00
Rate for Payer: Ohana Health Plan Medicare	$2.00
Rate for Payer: UnitedHealthcare Medicare	$2.00
Rate for Payer: University Health Alliance Commercial	$3.47

dexamethasone 4 mg Tab [KMC]

Facility

$4.76

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.62
Rate for Payer: Cash Price	$3.09
Rate for Payer: Health Management Network Commercial	$4.05
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: MDX Hawaii PPO	$4.62

dexamethasone/neomycin/polymyxin B Ophth Susp [KMC]

Facility

$35.20

Service Code	NDC 61314063006
Hospital Revenue Code	250
Min. Negotiated Rate	$29.92
Max. Negotiated Rate	$34.14
Rate for Payer: Cash Price	$22.88
Rate for Payer: Health Management Network Commercial	$29.92
Rate for Payer: Kaiser Permanente Commercial	$31.68
Rate for Payer: MDX Hawaii PPO	$34.14

dexamethasone/neomycin/polymyxin B Ophth Susp [KMC]

Facility

$35.20

Service Code	NDC 61314063006
Hospital Revenue Code	250
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$34.14
Rate for Payer: AlohaCare Medicaid	$17.60
Rate for Payer: AlohaCare Medicare	$14.78
Rate for Payer: Cash Price	$22.88
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$32.38
Rate for Payer: Devoted Health Medicare	$14.78
Rate for Payer: Hawaii Medical Service Association Medicare	$14.78
Rate for Payer: Hawaii Western Management Group Commercial	$33.44
Rate for Payer: Health Management Network Commercial	$29.92
Rate for Payer: Humana Medicare	$14.78
Rate for Payer: Kaiser Permanente Commercial	$31.68
Rate for Payer: Kaiser Permanente Medicaid	$17.95
Rate for Payer: Kaiser Permanente Medicare	$14.78
Rate for Payer: MDX Hawaii PPO	$34.14
Rate for Payer: Ohana Health Plan Medicaid	$14.78
Rate for Payer: Ohana Health Plan Medicare	$14.78
Rate for Payer: UnitedHealthcare Medicaid	$21.12
Rate for Payer: UnitedHealthcare Medicare	$14.78
Rate for Payer: University Health Alliance Commercial	$25.66

dexamethasone-neomyc.-polymyxin B eye ointment [KMC]

Facility

$50.29

Service Code	NDC 61314063136
Hospital Revenue Code	250
Min. Negotiated Rate	$21.12
Max. Negotiated Rate	$48.78
Rate for Payer: AlohaCare Medicaid	$25.14
Rate for Payer: AlohaCare Medicare	$21.12
Rate for Payer: Cash Price	$32.69
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.27
Rate for Payer: Devoted Health Medicare	$21.12
Rate for Payer: Hawaii Medical Service Association Medicare	$21.12
Rate for Payer: Hawaii Western Management Group Commercial	$47.78
Rate for Payer: Health Management Network Commercial	$42.75
Rate for Payer: Humana Medicare	$21.12
Rate for Payer: Kaiser Permanente Commercial	$45.26
Rate for Payer: Kaiser Permanente Medicaid	$25.65
Rate for Payer: Kaiser Permanente Medicare	$21.12
Rate for Payer: MDX Hawaii PPO	$48.78
Rate for Payer: Ohana Health Plan Medicaid	$21.12
Rate for Payer: Ohana Health Plan Medicare	$21.12
Rate for Payer: UnitedHealthcare Medicaid	$30.17
Rate for Payer: UnitedHealthcare Medicare	$21.12
Rate for Payer: University Health Alliance Commercial	$36.66

dexamethasone-neomyc.-polymyxin B eye ointment [KMC]

Facility

$50.29

Service Code	NDC 61314063136
Hospital Revenue Code	250
Min. Negotiated Rate	$42.75
Max. Negotiated Rate	$48.78
Rate for Payer: Cash Price	$32.69
Rate for Payer: Health Management Network Commercial	$42.75
Rate for Payer: Kaiser Permanente Commercial	$45.26
Rate for Payer: MDX Hawaii PPO	$48.78

DEXAMETHASONE SODIUM PHOS

Professional

Both

$9.00

Service Code	HCPCS J1100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$7.65
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$0.11
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Hawaii Western Management Group Commercial	$0.07
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$0.13
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.11

dexmedetomidine 400 mcg / 100 mL NS IV bottle

Facility

$2.40

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$2.33
Rate for Payer: Cash Price	$1.56
Rate for Payer: Health Management Network Commercial	$2.04
Rate for Payer: Kaiser Permanente Commercial	$2.16
Rate for Payer: MDX Hawaii PPO	$2.33

dexmedetomidine 400 mcg / 100 mL NS IV bottle

Facility

$2.40

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2.33
Rate for Payer: AlohaCare Medicaid	$1.20
Rate for Payer: AlohaCare Medicare	$1.01
Rate for Payer: Cash Price	$1.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.21
Rate for Payer: Devoted Health Medicare	$1.01
Rate for Payer: Hawaii Medical Service Association Medicare	$1.01
Rate for Payer: Hawaii Western Management Group Commercial	$2.28
Rate for Payer: Health Management Network Commercial	$2.04
Rate for Payer: Humana Medicare	$1.01
Rate for Payer: Kaiser Permanente Commercial	$2.16
Rate for Payer: Kaiser Permanente Medicaid	$1.22
Rate for Payer: Kaiser Permanente Medicare	$1.01
Rate for Payer: MDX Hawaii PPO	$2.33
Rate for Payer: Ohana Health Plan Medicaid	$1.01
Rate for Payer: Ohana Health Plan Medicare	$1.01
Rate for Payer: UnitedHealthcare Medicaid	$1.44
Rate for Payer: UnitedHealthcare Medicare	$1.01
Rate for Payer: University Health Alliance Commercial	$1.75

dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL Oral Liq [KMC]

Facility

$0.17

Service Code	NDC 58657050408
Hospital Revenue Code	250
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

dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL Oral Liq [KMC]

Facility

$0.17

Service Code	NDC 58657050408
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: AlohaCare Medicaid	$0.09
Rate for Payer: AlohaCare Medicare	$0.07
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 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

Dextrose 10% in Water 500 mL IV Solution [KMC]

Facility

$0.03

Service Code	NDC 00264752010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Management Network Commercial	$0.03
Rate for Payer: Kaiser Permanente Commercial	$0.03
Rate for Payer: MDX Hawaii PPO	$0.03

Dextrose 10% in Water 500 mL IV Solution [KMC]

Facility

$0.03

Service Code	NDC 00264752010
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: AlohaCare Medicaid	$0.02
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.03
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$0.03
Rate for Payer: Health Management Network Commercial	$0.03
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.03
Rate for Payer: Kaiser Permanente Medicaid	$0.02
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.03
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicaid	$0.02
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.02

Dextrose 25% (2.5 gm / 10 mL) IV Soln [KMC]

Facility

$5.58

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$5.41
Rate for Payer: Cash Price	$3.63
Rate for Payer: Health Management Network Commercial	$4.74
Rate for Payer: Kaiser Permanente Commercial	$5.02
Rate for Payer: MDX Hawaii PPO	$5.41

Dextrose 25% (2.5 gm / 10 mL) IV Soln [KMC]

Facility

$5.58

Service Code	NDC 00409177510
Hospital Revenue Code	250
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$5.41
Rate for Payer: AlohaCare Medicaid	$2.79
Rate for Payer: AlohaCare Medicare	$2.34
Rate for Payer: Cash Price	$3.63
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.13
Rate for Payer: Devoted Health Medicare	$2.34
Rate for Payer: Hawaii Medical Service Association Medicare	$2.34
Rate for Payer: Hawaii Western Management Group Commercial	$5.30
Rate for Payer: Health Management Network Commercial	$4.74
Rate for Payer: Humana Medicare	$2.34
Rate for Payer: Kaiser Permanente Commercial	$5.02
Rate for Payer: Kaiser Permanente Medicaid	$2.85
Rate for Payer: Kaiser Permanente Medicare	$2.34
Rate for Payer: MDX Hawaii PPO	$5.41
Rate for Payer: Ohana Health Plan Medicaid	$2.34
Rate for Payer: Ohana Health Plan Medicare	$2.34
Rate for Payer: UnitedHealthcare Medicaid	$3.35
Rate for Payer: UnitedHealthcare Medicare	$2.34
Rate for Payer: University Health Alliance Commercial	$4.07

Dextrose 50% (25 g / 50 mL) IV Soln [KMC]

Facility

$1.07

Service Code	NDC 00409751716
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$1.04
Rate for Payer: AlohaCare Medicaid	$0.54
Rate for Payer: AlohaCare Medicare	$0.45
Rate for Payer: Cash Price	$0.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.98
Rate for Payer: Devoted Health Medicare	$0.45
Rate for Payer: Hawaii Medical Service Association Medicare	$0.45
Rate for Payer: Hawaii Western Management Group Commercial	$1.02
Rate for Payer: Health Management Network Commercial	$0.91
Rate for Payer: Humana Medicare	$0.45
Rate for Payer: Kaiser Permanente Commercial	$0.96
Rate for Payer: Kaiser Permanente Medicaid	$0.55
Rate for Payer: Kaiser Permanente Medicare	$0.45
Rate for Payer: MDX Hawaii PPO	$1.04
Rate for Payer: Ohana Health Plan Medicaid	$0.45
Rate for Payer: Ohana Health Plan Medicare	$0.45
Rate for Payer: UnitedHealthcare Medicaid	$0.64
Rate for Payer: UnitedHealthcare Medicare	$0.45
Rate for Payer: University Health Alliance Commercial	$0.78

Dextrose 50% (25 g / 50 mL) IV Soln [KMC]

Facility

$1.07

Service Code	NDC 00409751716
Hospital Revenue Code	250
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.70
Rate for Payer: Health Management Network Commercial	$0.91
Rate for Payer: Kaiser Permanente Commercial	$0.96
Rate for Payer: MDX Hawaii PPO	$1.04

Dextrose 5% and 0.45% NaCl 1000 mL IV bag [KMC]

Facility

$0.03

Service Code	HCPCS S5010
Hospital Revenue Code	637
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Management Network Commercial	$0.03
Rate for Payer: Kaiser Permanente Commercial	$0.03
Rate for Payer: MDX Hawaii PPO	$0.03

Dextrose 5% and 0.45% NaCl 1000 mL IV bag [KMC]

Facility

$0.03

Service Code	HCPCS S5010
Hospital Revenue Code	637
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: AlohaCare Medicaid	$0.02
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.03
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$0.03
Rate for Payer: Health Management Network Commercial	$0.03
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.03
Rate for Payer: Kaiser Permanente Medicaid	$0.02
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.03
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.02

Know your out-of-pocket cost for care.

All Charges