Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Dextrose 5% in Lactated Ringers 1000 mL IV bag [KMC]

Facility

$0.03

Service Code	HCPCS J7121
Hospital Revenue Code	636
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: 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 ABD/Non-ABD	$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 5% in Lactated Ringers 1000 mL IV bag [KMC]

Facility

$0.03

Service Code	HCPCS J7121
Hospital Revenue Code	636
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% with 0.9% NaCl Sol [KMC]

Facility

$0.05

Service Code	HCPCS J7042
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Management Network Commercial	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: MDX Hawaii PPO	$0.05

Dextrose 5% with 0.9% NaCl Sol [KMC]

Facility

$0.05

Service Code	HCPCS J7042
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$1.36
Rate for Payer: AlohaCare Medicaid	$0.03
Rate for Payer: AlohaCare Medicare	$0.02
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.36
Rate for Payer: Hawaii Medical Service Association Medicare	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$0.05
Rate for Payer: Health Management Network Commercial	$0.04
Rate for Payer: Humana Medicare	$0.02
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: Kaiser Permanente Medicaid	$0.03
Rate for Payer: Kaiser Permanente Medicare	$0.02
Rate for Payer: MDX Hawaii PPO	$0.05
Rate for Payer: Ohana Health Plan Medicaid	$0.02
Rate for Payer: Ohana Health Plan Medicare	$0.02
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicare	$0.02
Rate for Payer: University Health Alliance Commercial	$0.04

DHEA DLS

Facility

$357.00

Service Code	HCPCS 82626
Hospital Charge Code	422826265
Hospital Revenue Code	301
Min. Negotiated Rate	$303.45
Max. Negotiated Rate	$346.29
Rate for Payer: Cash Price	$232.05
Rate for Payer: Health Management Network Commercial	$303.45
Rate for Payer: Kaiser Permanente Commercial	$321.30
Rate for Payer: MDX Hawaii PPO	$346.29

DHEA DLS

Facility

$357.00

Service Code	HCPCS 82626
Hospital Charge Code	422826265
Hospital Revenue Code	301
Min. Negotiated Rate	$25.27
Max. Negotiated Rate	$346.29
Rate for Payer: AlohaCare Medicaid	$178.50
Rate for Payer: AlohaCare Medicare	$149.94
Rate for Payer: Cash Price	$232.05
Rate for Payer: Cash Price	$232.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$328.44
Rate for Payer: Devoted Health Medicare	$149.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$34.93
Rate for Payer: Hawaii Medical Service Association Commercial	$31.59
Rate for Payer: Hawaii Medical Service Association Medicare	$149.94
Rate for Payer: Hawaii Western Management Group Commercial	$25.27
Rate for Payer: Health Management Network Commercial	$303.45
Rate for Payer: Humana Medicare	$149.94
Rate for Payer: Kaiser Permanente Commercial	$321.30
Rate for Payer: Kaiser Permanente Medicaid	$182.07
Rate for Payer: Kaiser Permanente Medicare	$149.94
Rate for Payer: MDX Hawaii PPO	$346.29
Rate for Payer: Ohana Health Plan Medicaid	$149.94
Rate for Payer: Ohana Health Plan Medicare	$149.94
Rate for Payer: UnitedHealthcare Medicaid	$34.93
Rate for Payer: UnitedHealthcare Medicare	$149.94
Rate for Payer: University Health Alliance Commercial	$65.32

DHEA-Sulfate DLS

Facility

$447.00

Service Code	HCPCS 82627
Hospital Charge Code	422826275
Hospital Revenue Code	301
Min. Negotiated Rate	$22.23
Max. Negotiated Rate	$433.59
Rate for Payer: AlohaCare Medicaid	$223.50
Rate for Payer: AlohaCare Medicare	$187.74
Rate for Payer: Cash Price	$290.55
Rate for Payer: Cash Price	$290.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$411.24
Rate for Payer: Devoted Health Medicare	$187.74
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$30.72
Rate for Payer: Hawaii Medical Service Association Commercial	$27.79
Rate for Payer: Hawaii Medical Service Association Medicare	$187.74
Rate for Payer: Hawaii Western Management Group Commercial	$22.23
Rate for Payer: Health Management Network Commercial	$379.95
Rate for Payer: Humana Medicare	$187.74
Rate for Payer: Kaiser Permanente Commercial	$402.30
Rate for Payer: Kaiser Permanente Medicaid	$227.97
Rate for Payer: Kaiser Permanente Medicare	$187.74
Rate for Payer: MDX Hawaii PPO	$433.59
Rate for Payer: Ohana Health Plan Medicaid	$187.74
Rate for Payer: Ohana Health Plan Medicare	$187.74
Rate for Payer: UnitedHealthcare Medicaid	$30.72
Rate for Payer: UnitedHealthcare Medicare	$187.74
Rate for Payer: University Health Alliance Commercial	$57.48

DHEA-Sulfate DLS

Facility

$447.00

Service Code	HCPCS 82627
Hospital Charge Code	422826275
Hospital Revenue Code	301
Min. Negotiated Rate	$379.95
Max. Negotiated Rate	$433.59
Rate for Payer: Cash Price	$290.55
Rate for Payer: Health Management Network Commercial	$379.95
Rate for Payer: Kaiser Permanente Commercial	$402.30
Rate for Payer: MDX Hawaii PPO	$433.59

DIABETES WITH CC

Facility

$14,932.26

Service Code	MSDRG 638
Min. Negotiated Rate	$14,932.26
Max. Negotiated Rate	$14,932.26
Rate for Payer: Hawaii Medical Service Association Commercial	$14,932.26

DIABETES WITH MCC

Facility

$15,074.47

Service Code	MSDRG 637
Min. Negotiated Rate	$15,074.47
Max. Negotiated Rate	$15,074.47
Rate for Payer: Hawaii Medical Service Association Commercial	$15,074.47

DIABETES WITHOUT CC/MCC

Facility

$14,813.75

Service Code	MSDRG 639
Min. Negotiated Rate	$14,813.75
Max. Negotiated Rate	$14,813.75
Rate for Payer: Hawaii Medical Service Association Commercial	$14,813.75

diazePAM 10 mg/2 mL Carpuject Syringe [KMC]

Facility

$19.44

Service Code	HCPCS J3360
Hospital Revenue Code	636
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$18.86
Rate for Payer: AlohaCare Medicaid	$9.72
Rate for Payer: AlohaCare Medicare	$8.16
Rate for Payer: Cash Price	$12.64
Rate for Payer: Cash Price	$12.64
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$17.88
Rate for Payer: Devoted Health Medicare	$8.16
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Medicare	$8.16
Rate for Payer: Hawaii Western Management Group Commercial	$18.47
Rate for Payer: Health Management Network Commercial	$16.52
Rate for Payer: Humana Medicare	$8.16
Rate for Payer: Kaiser Permanente Commercial	$17.50
Rate for Payer: Kaiser Permanente Medicaid	$9.91
Rate for Payer: Kaiser Permanente Medicare	$8.16
Rate for Payer: MDX Hawaii PPO	$18.86
Rate for Payer: Ohana Health Plan Medicaid	$8.16
Rate for Payer: Ohana Health Plan Medicare	$8.16
Rate for Payer: UnitedHealthcare Medicaid	$11.66
Rate for Payer: UnitedHealthcare Medicare	$8.16
Rate for Payer: University Health Alliance Commercial	$14.17

diazePAM 10 mg/2 mL Carpuject Syringe [KMC]

Facility

$19.44

Service Code	HCPCS J3360
Hospital Revenue Code	636
Min. Negotiated Rate	$16.52
Max. Negotiated Rate	$18.86
Rate for Payer: Cash Price	$12.64
Rate for Payer: Health Management Network Commercial	$16.52
Rate for Payer: Kaiser Permanente Commercial	$17.50
Rate for Payer: MDX Hawaii PPO	$18.86

diazePAM 2 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079028420
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

diazePAM 2 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079028420
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

diazepam 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079028520
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

diazepam 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 51079028520
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

dibucaine topical 1% Oint [KMC]

Facility

$0.39

Service Code	NDC 71399282902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: MDX Hawaii PPO	$0.38

dibucaine topical 1% Oint [KMC]

Facility

$0.39

Service Code	NDC 71399282902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.38
Rate for Payer: AlohaCare Medicaid	$0.20
Rate for Payer: AlohaCare Medicare	$0.16
Rate for Payer: Cash Price	$0.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.36
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$0.37
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Humana Medicare	$0.16
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: Kaiser Permanente Medicaid	$0.20
Rate for Payer: Kaiser Permanente Medicare	$0.16
Rate for Payer: MDX Hawaii PPO	$0.38
Rate for Payer: Ohana Health Plan Medicaid	$0.16
Rate for Payer: Ohana Health Plan Medicare	$0.16
Rate for Payer: UnitedHealthcare Medicaid	$0.23
Rate for Payer: UnitedHealthcare Medicare	$0.16
Rate for Payer: University Health Alliance Commercial	$0.28

diclofenac 1% Gel [KMC]

Facility

$2.33

Service Code	NDC 21922000909
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.51
Rate for Payer: Health Management Network Commercial	$1.98
Rate for Payer: Kaiser Permanente Commercial	$2.10
Rate for Payer: MDX Hawaii PPO	$2.26

diclofenac 1% Gel [KMC]

Facility

$2.33

Service Code	NDC 21922000909
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$2.26
Rate for Payer: AlohaCare Medicaid	$1.17
Rate for Payer: AlohaCare Medicare	$0.98
Rate for Payer: Cash Price	$1.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.14
Rate for Payer: Devoted Health Medicare	$0.98
Rate for Payer: Hawaii Medical Service Association Medicare	$0.98
Rate for Payer: Hawaii Western Management Group Commercial	$2.21
Rate for Payer: Health Management Network Commercial	$1.98
Rate for Payer: Humana Medicare	$0.98
Rate for Payer: Kaiser Permanente Commercial	$2.10
Rate for Payer: Kaiser Permanente Medicaid	$1.19
Rate for Payer: Kaiser Permanente Medicare	$0.98
Rate for Payer: MDX Hawaii PPO	$2.26
Rate for Payer: Ohana Health Plan Medicaid	$0.98
Rate for Payer: Ohana Health Plan Medicare	$0.98
Rate for Payer: UnitedHealthcare Medicaid	$1.40
Rate for Payer: UnitedHealthcare Medicare	$0.98
Rate for Payer: University Health Alliance Commercial	$1.70

diclofenac sodium 75 mg EC [KMC]

Facility

$4.59

Service Code	NDC 00228255106
Hospital Revenue Code	250
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$4.45
Rate for Payer: Cash Price	$2.98
Rate for Payer: Health Management Network Commercial	$3.90
Rate for Payer: Kaiser Permanente Commercial	$4.13
Rate for Payer: MDX Hawaii PPO	$4.45

diclofenac sodium 75 mg EC [KMC]

Facility

$4.59

Service Code	NDC 00228255106
Hospital Revenue Code	250
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$4.45
Rate for Payer: AlohaCare Medicaid	$2.29
Rate for Payer: AlohaCare Medicare	$1.93
Rate for Payer: Cash Price	$2.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.22
Rate for Payer: Devoted Health Medicare	$1.93
Rate for Payer: Hawaii Medical Service Association Medicare	$1.93
Rate for Payer: Hawaii Western Management Group Commercial	$4.36
Rate for Payer: Health Management Network Commercial	$3.90
Rate for Payer: Humana Medicare	$1.93
Rate for Payer: Kaiser Permanente Commercial	$4.13
Rate for Payer: Kaiser Permanente Medicaid	$2.34
Rate for Payer: Kaiser Permanente Medicare	$1.93
Rate for Payer: MDX Hawaii PPO	$4.45
Rate for Payer: Ohana Health Plan Medicaid	$1.93
Rate for Payer: Ohana Health Plan Medicare	$1.93
Rate for Payer: UnitedHealthcare Medicaid	$2.75
Rate for Payer: UnitedHealthcare Medicare	$1.93
Rate for Payer: University Health Alliance Commercial	$3.35

diclofenac topical 1.3% patch

Facility

$51.02

Service Code	NDC 82347040505
Hospital Revenue Code	250
Min. Negotiated Rate	$21.43
Max. Negotiated Rate	$49.49
Rate for Payer: AlohaCare Medicaid	$25.51
Rate for Payer: AlohaCare Medicare	$21.43
Rate for Payer: Cash Price	$33.16
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.94
Rate for Payer: Devoted Health Medicare	$21.43
Rate for Payer: Hawaii Medical Service Association Medicare	$21.43
Rate for Payer: Hawaii Western Management Group Commercial	$48.47
Rate for Payer: Health Management Network Commercial	$43.37
Rate for Payer: Humana Medicare	$21.43
Rate for Payer: Kaiser Permanente Commercial	$45.92
Rate for Payer: Kaiser Permanente Medicaid	$26.02
Rate for Payer: Kaiser Permanente Medicare	$21.43
Rate for Payer: MDX Hawaii PPO	$49.49
Rate for Payer: Ohana Health Plan Medicaid	$21.43
Rate for Payer: Ohana Health Plan Medicare	$21.43
Rate for Payer: UnitedHealthcare Medicaid	$30.61
Rate for Payer: UnitedHealthcare Medicare	$21.43
Rate for Payer: University Health Alliance Commercial	$37.19

diclofenac topical 1.3% patch

Facility

$51.02

Service Code	NDC 82347040505
Hospital Revenue Code	250
Min. Negotiated Rate	$43.37
Max. Negotiated Rate	$49.49
Rate for Payer: Cash Price	$33.16
Rate for Payer: Health Management Network Commercial	$43.37
Rate for Payer: Kaiser Permanente Commercial	$45.92
Rate for Payer: MDX Hawaii PPO	$49.49

Know your out-of-pocket cost for care.

All Charges