Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

dicloxacillin 500 mg Cap [KMC]

Facility

$10.02

Service Code	NDC 59651056601
Hospital Revenue Code	250
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$9.72
Rate for Payer: AlohaCare Medicaid	$5.01
Rate for Payer: AlohaCare Medicare	$4.21
Rate for Payer: Cash Price	$6.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.22
Rate for Payer: Devoted Health Medicare	$4.21
Rate for Payer: Hawaii Medical Service Association Medicare	$4.21
Rate for Payer: Hawaii Western Management Group Commercial	$9.52
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Humana Medicare	$4.21
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: Kaiser Permanente Medicaid	$5.11
Rate for Payer: Kaiser Permanente Medicare	$4.21
Rate for Payer: MDX Hawaii PPO	$9.72
Rate for Payer: Ohana Health Plan Medicaid	$4.21
Rate for Payer: Ohana Health Plan Medicare	$4.21
Rate for Payer: UnitedHealthcare Medicaid	$6.01
Rate for Payer: UnitedHealthcare Medicare	$4.21
Rate for Payer: University Health Alliance Commercial	$7.30

dicloxacillin 500 mg Cap [KMC]

Facility

$10.02

Service Code	NDC 59651056601
Hospital Revenue Code	250
Min. Negotiated Rate	$8.52
Max. Negotiated Rate	$9.72
Rate for Payer: Cash Price	$6.51
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: MDX Hawaii PPO	$9.72

dicyclomine 10 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 24979020101
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

dicyclomine 10 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 24979020101
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

dicyclomine 20 mg/2mL Inj Sol [KMC]

Facility

$201.74

Service Code	HCPCS J0500
Hospital Revenue Code	636
Min. Negotiated Rate	$171.48
Max. Negotiated Rate	$195.69
Rate for Payer: Cash Price	$131.13
Rate for Payer: Health Management Network Commercial	$171.48
Rate for Payer: Kaiser Permanente Commercial	$181.57
Rate for Payer: MDX Hawaii PPO	$195.69

dicyclomine 20 mg/2mL Inj Sol [KMC]

Facility

$201.74

Service Code	HCPCS J0500
Hospital Revenue Code	636
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$195.69
Rate for Payer: AlohaCare Medicaid	$100.87
Rate for Payer: AlohaCare Medicare	$84.73
Rate for Payer: Cash Price	$131.13
Rate for Payer: Cash Price	$131.13
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$185.60
Rate for Payer: Devoted Health Medicare	$84.73
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.68
Rate for Payer: Hawaii Medical Service Association Medicare	$84.73
Rate for Payer: Hawaii Western Management Group Commercial	$191.65
Rate for Payer: Health Management Network Commercial	$171.48
Rate for Payer: Humana Medicare	$84.73
Rate for Payer: Kaiser Permanente Commercial	$181.57
Rate for Payer: Kaiser Permanente Medicaid	$102.89
Rate for Payer: Kaiser Permanente Medicare	$84.73
Rate for Payer: MDX Hawaii PPO	$195.69
Rate for Payer: Ohana Health Plan Medicaid	$84.73
Rate for Payer: Ohana Health Plan Medicare	$84.73
Rate for Payer: UnitedHealthcare Medicaid	$121.04
Rate for Payer: UnitedHealthcare Medicare	$84.73
Rate for Payer: University Health Alliance Commercial	$147.05

dicyclomine 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00527128201
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

dicyclomine 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00527128201
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

DIGESTIVE MALIGNANCY WITH CC

Facility

$54,633.11

Service Code	MSDRG 375
Min. Negotiated Rate	$54,633.11
Max. Negotiated Rate	$54,633.11
Rate for Payer: Hawaii Medical Service Association Commercial	$54,633.11

DIGESTIVE MALIGNANCY WITH MCC

Facility

$55,936.72

Service Code	MSDRG 374
Min. Negotiated Rate	$55,936.72
Max. Negotiated Rate	$55,936.72
Rate for Payer: Hawaii Medical Service Association Commercial	$55,936.72

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$28,489.80

Service Code	MSDRG 376
Min. Negotiated Rate	$28,489.80
Max. Negotiated Rate	$28,489.80
Rate for Payer: Hawaii Medical Service Association Commercial	$28,489.80

digoxin 125 mcg Tab [KMC]

Facility

$9.20

Service Code	NDC 70954020110
Hospital Revenue Code	250
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$8.92
Rate for Payer: AlohaCare Medicaid	$4.60
Rate for Payer: AlohaCare Medicare	$3.86
Rate for Payer: Cash Price	$5.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.46
Rate for Payer: Devoted Health Medicare	$3.86
Rate for Payer: Hawaii Medical Service Association Medicare	$3.86
Rate for Payer: Hawaii Western Management Group Commercial	$8.74
Rate for Payer: Health Management Network Commercial	$7.82
Rate for Payer: Humana Medicare	$3.86
Rate for Payer: Kaiser Permanente Commercial	$8.28
Rate for Payer: Kaiser Permanente Medicaid	$4.69
Rate for Payer: Kaiser Permanente Medicare	$3.86
Rate for Payer: MDX Hawaii PPO	$8.92
Rate for Payer: Ohana Health Plan Medicaid	$3.86
Rate for Payer: Ohana Health Plan Medicare	$3.86
Rate for Payer: UnitedHealthcare Medicaid	$5.52
Rate for Payer: UnitedHealthcare Medicare	$3.86
Rate for Payer: University Health Alliance Commercial	$6.71

digoxin 125 mcg Tab [KMC]

Facility

$9.20

Service Code	NDC 70954020110
Hospital Revenue Code	250
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$8.92
Rate for Payer: Cash Price	$5.98
Rate for Payer: Health Management Network Commercial	$7.82
Rate for Payer: Kaiser Permanente Commercial	$8.28
Rate for Payer: MDX Hawaii PPO	$8.92

digoxin 250 mcg/mL (0.25 mg/mL) Sol [KMC]

Facility

$13.20

Service Code	HCPCS J1160
Hospital Revenue Code	636
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$12.80
Rate for Payer: Cash Price	$8.58
Rate for Payer: Health Management Network Commercial	$11.22
Rate for Payer: Kaiser Permanente Commercial	$11.88
Rate for Payer: MDX Hawaii PPO	$12.80

digoxin 250 mcg/mL (0.25 mg/mL) Sol [KMC]

Facility

$13.20

Service Code	HCPCS J1160
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$12.80
Rate for Payer: AlohaCare Medicaid	$6.60
Rate for Payer: AlohaCare Medicare	$5.54
Rate for Payer: Cash Price	$8.58
Rate for Payer: Cash Price	$8.58
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.14
Rate for Payer: Devoted Health Medicare	$5.54
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Medicare	$5.54
Rate for Payer: Hawaii Western Management Group Commercial	$12.54
Rate for Payer: Health Management Network Commercial	$11.22
Rate for Payer: Humana Medicare	$5.54
Rate for Payer: Kaiser Permanente Commercial	$11.88
Rate for Payer: Kaiser Permanente Medicaid	$6.73
Rate for Payer: Kaiser Permanente Medicare	$5.54
Rate for Payer: MDX Hawaii PPO	$12.80
Rate for Payer: Ohana Health Plan Medicaid	$5.54
Rate for Payer: Ohana Health Plan Medicare	$5.54
Rate for Payer: UnitedHealthcare Medicaid	$7.92
Rate for Payer: UnitedHealthcare Medicare	$5.54
Rate for Payer: University Health Alliance Commercial	$9.62

Digoxin DLS

Facility

$251.00

Service Code	HCPCS 80162
Hospital Charge Code	422801625
Hospital Revenue Code	301
Min. Negotiated Rate	$213.35
Max. Negotiated Rate	$243.47
Rate for Payer: Cash Price	$163.15
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: MDX Hawaii PPO	$243.47

Digoxin DLS

Facility

$251.00

Service Code	HCPCS 80162
Hospital Charge Code	422801625
Hospital Revenue Code	301
Min. Negotiated Rate	$13.28
Max. Negotiated Rate	$243.47
Rate for Payer: AlohaCare Medicaid	$125.50
Rate for Payer: AlohaCare Medicare	$105.42
Rate for Payer: Cash Price	$163.15
Rate for Payer: Cash Price	$163.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$230.92
Rate for Payer: Devoted Health Medicare	$105.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.35
Rate for Payer: Hawaii Medical Service Association Commercial	$16.60
Rate for Payer: Hawaii Medical Service Association Medicare	$105.42
Rate for Payer: Hawaii Western Management Group Commercial	$13.28
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Humana Medicare	$105.42
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: Kaiser Permanente Medicaid	$128.01
Rate for Payer: Kaiser Permanente Medicare	$105.42
Rate for Payer: MDX Hawaii PPO	$243.47
Rate for Payer: Ohana Health Plan Medicaid	$105.42
Rate for Payer: Ohana Health Plan Medicare	$105.42
Rate for Payer: UnitedHealthcare Medicaid	$18.35
Rate for Payer: UnitedHealthcare Medicare	$105.42
Rate for Payer: University Health Alliance Commercial	$34.32

Dilantin DLS

Facility

$113.00

Service Code	HCPCS 80185
Hospital Charge Code	422801855
Hospital Revenue Code	301
Min. Negotiated Rate	$13.25
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: 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 ABD/Non-ABD	$18.32
Rate for Payer: Hawaii Medical Service Association Commercial	$16.56
Rate for Payer: Hawaii Medical Service Association Medicare	$47.46
Rate for Payer: Hawaii Western Management Group Commercial	$13.25
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 Medicaid	$18.32
Rate for Payer: UnitedHealthcare Medicare	$47.46
Rate for Payer: University Health Alliance Commercial	$34.26

Dilantin DLS

Facility

$113.00

Service Code	HCPCS 80185
Hospital Charge Code	422801855
Hospital Revenue Code	301
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

DILATED RETINAL EXAM W/EVIDENCE OF RETINOPATHY

Professional

Both

$0.01

Service Code	HCPCS 2022F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

DILATED RETINAL EXAM W/O EVIDENCE OF RETINOPATHY

Professional

Both

$0.01

Service Code	HCPCS 2023F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

diltiazem 120 mg/24 hours ER Cap [KMC]

Facility

$4.79

Service Code	NDC 47335067581
Hospital Revenue Code	250
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$4.65
Rate for Payer: AlohaCare Medicaid	$2.40
Rate for Payer: AlohaCare Medicare	$2.01
Rate for Payer: Cash Price	$3.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.41
Rate for Payer: Devoted Health Medicare	$2.01
Rate for Payer: Hawaii Medical Service Association Medicare	$2.01
Rate for Payer: Hawaii Western Management Group Commercial	$4.55
Rate for Payer: Health Management Network Commercial	$4.07
Rate for Payer: Humana Medicare	$2.01
Rate for Payer: Kaiser Permanente Commercial	$4.31
Rate for Payer: Kaiser Permanente Medicaid	$2.44
Rate for Payer: Kaiser Permanente Medicare	$2.01
Rate for Payer: MDX Hawaii PPO	$4.65
Rate for Payer: Ohana Health Plan Medicaid	$2.01
Rate for Payer: Ohana Health Plan Medicare	$2.01
Rate for Payer: UnitedHealthcare Medicaid	$2.87
Rate for Payer: UnitedHealthcare Medicare	$2.01
Rate for Payer: University Health Alliance Commercial	$3.49

diltiazem 120 mg/24 hours ER Cap [KMC]

Facility

$4.79

Service Code	NDC 47335067581
Hospital Revenue Code	250
Min. Negotiated Rate	$4.07
Max. Negotiated Rate	$4.65
Rate for Payer: Cash Price	$3.11
Rate for Payer: Health Management Network Commercial	$4.07
Rate for Payer: Kaiser Permanente Commercial	$4.31
Rate for Payer: MDX Hawaii PPO	$4.65

dilTIAZem 125 mg / 25 mL Soln [KMC]

Facility

$1.11

Service Code	NDC 00641921910
Hospital Revenue Code	250
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.08
Rate for Payer: Cash Price	$0.72
Rate for Payer: Health Management Network Commercial	$0.94
Rate for Payer: Kaiser Permanente Commercial	$1.00
Rate for Payer: MDX Hawaii PPO	$1.08

dilTIAZem 125 mg / 25 mL Soln [KMC]

Facility

$1.11

Service Code	NDC 00641921910
Hospital Revenue Code	250
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$1.08
Rate for Payer: AlohaCare Medicaid	$0.56
Rate for Payer: AlohaCare Medicare	$0.47
Rate for Payer: Cash Price	$0.72
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.02
Rate for Payer: Devoted Health Medicare	$0.47
Rate for Payer: Hawaii Medical Service Association Medicare	$0.47
Rate for Payer: Hawaii Western Management Group Commercial	$1.05
Rate for Payer: Health Management Network Commercial	$0.94
Rate for Payer: Humana Medicare	$0.47
Rate for Payer: Kaiser Permanente Commercial	$1.00
Rate for Payer: Kaiser Permanente Medicaid	$0.57
Rate for Payer: Kaiser Permanente Medicare	$0.47
Rate for Payer: MDX Hawaii PPO	$1.08
Rate for Payer: Ohana Health Plan Medicaid	$0.47
Rate for Payer: Ohana Health Plan Medicare	$0.47
Rate for Payer: UnitedHealthcare Medicaid	$0.67
Rate for Payer: UnitedHealthcare Medicare	$0.47
Rate for Payer: University Health Alliance Commercial	$0.81

Know your out-of-pocket cost for care.

All Charges