Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

diltiazem 180 mg ER Cap [KMC]

Facility

$7.23

Service Code	NDC 63739028410
Hospital Revenue Code	250
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$7.01
Rate for Payer: AlohaCare Medicaid	$3.62
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$4.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.65
Rate for Payer: Devoted Health Medicare	$3.04
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$6.87
Rate for Payer: Health Management Network Commercial	$6.15
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$6.51
Rate for Payer: Kaiser Permanente Medicaid	$3.69
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$7.01
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicaid	$4.34
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$5.27

diltiazem 180 mg ER Cap [KMC]

Facility

$7.23

Service Code	NDC 63739028410
Hospital Revenue Code	250
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$7.01
Rate for Payer: Cash Price	$4.70
Rate for Payer: Health Management Network Commercial	$6.15
Rate for Payer: Kaiser Permanente Commercial	$6.51
Rate for Payer: MDX Hawaii PPO	$7.01

diltiazem 240 mg/24 hours ER Cap [KMC]

Facility

$5.60

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$5.43
Rate for Payer: AlohaCare Medicaid	$2.80
Rate for Payer: AlohaCare Medicare	$2.35
Rate for Payer: Cash Price	$3.64
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.15
Rate for Payer: Devoted Health Medicare	$2.35
Rate for Payer: Hawaii Medical Service Association Medicare	$2.35
Rate for Payer: Hawaii Western Management Group Commercial	$5.32
Rate for Payer: Health Management Network Commercial	$4.76
Rate for Payer: Humana Medicare	$2.35
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$2.86
Rate for Payer: Kaiser Permanente Medicare	$2.35
Rate for Payer: MDX Hawaii PPO	$5.43
Rate for Payer: Ohana Health Plan Medicaid	$2.35
Rate for Payer: Ohana Health Plan Medicare	$2.35
Rate for Payer: UnitedHealthcare Medicare	$2.35
Rate for Payer: University Health Alliance Commercial	$4.08

diltiazem 240 mg/24 hours ER Cap [KMC]

Facility

$5.60

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$5.43
Rate for Payer: Cash Price	$3.64
Rate for Payer: Health Management Network Commercial	$4.76
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: MDX Hawaii PPO	$5.43

diltiazem 25 mg / 5 mL IV Sol [KMC]

Facility

$2.09

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$2.03
Rate for Payer: AlohaCare Medicaid	$1.04
Rate for Payer: AlohaCare Medicare	$0.88
Rate for Payer: Cash Price	$1.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.92
Rate for Payer: Devoted Health Medicare	$0.88
Rate for Payer: Hawaii Medical Service Association Medicare	$0.88
Rate for Payer: Hawaii Western Management Group Commercial	$1.99
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: Humana Medicare	$0.88
Rate for Payer: Kaiser Permanente Commercial	$1.88
Rate for Payer: Kaiser Permanente Medicaid	$1.07
Rate for Payer: Kaiser Permanente Medicare	$0.88
Rate for Payer: MDX Hawaii PPO	$2.03
Rate for Payer: Ohana Health Plan Medicaid	$0.88
Rate for Payer: Ohana Health Plan Medicare	$0.88
Rate for Payer: UnitedHealthcare Medicaid	$1.25
Rate for Payer: UnitedHealthcare Medicare	$0.88
Rate for Payer: University Health Alliance Commercial	$1.52

diltiazem 25 mg / 5 mL IV Sol [KMC]

Facility

$2.09

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.03
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Management Network Commercial	$1.78
Rate for Payer: Kaiser Permanente Commercial	$1.88
Rate for Payer: MDX Hawaii PPO	$2.03

diltiazem 30 mg Tab [KMC]

Facility

$4.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

diltiazem 30 mg Tab [KMC]

Facility

$4.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

dilTIAZem 50 mg/10 mL Soln [KMC]

Facility

$1.46

Service Code	NDC 17478093710
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.42
Rate for Payer: AlohaCare Medicaid	$0.73
Rate for Payer: AlohaCare Medicare	$0.61
Rate for Payer: Cash Price	$0.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.34
Rate for Payer: Devoted Health Medicare	$0.61
Rate for Payer: Hawaii Medical Service Association Medicare	$0.61
Rate for Payer: Hawaii Western Management Group Commercial	$1.39
Rate for Payer: Health Management Network Commercial	$1.24
Rate for Payer: Humana Medicare	$0.61
Rate for Payer: Kaiser Permanente Commercial	$1.31
Rate for Payer: Kaiser Permanente Medicaid	$0.74
Rate for Payer: Kaiser Permanente Medicare	$0.61
Rate for Payer: MDX Hawaii PPO	$1.42
Rate for Payer: Ohana Health Plan Medicaid	$0.61
Rate for Payer: Ohana Health Plan Medicare	$0.61
Rate for Payer: UnitedHealthcare Medicaid	$0.88
Rate for Payer: UnitedHealthcare Medicare	$0.61
Rate for Payer: University Health Alliance Commercial	$1.06

dilTIAZem 50 mg/10 mL Soln [KMC]

Facility

$1.46

Service Code	NDC 17478093710
Hospital Revenue Code	250
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.42
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Management Network Commercial	$1.24
Rate for Payer: Kaiser Permanente Commercial	$1.31
Rate for Payer: MDX Hawaii PPO	$1.42

dilTIAZem 60 mg ER (12-hour) Cap [KMC]

Facility

$13.83

Service Code	NDC 16714055301
Hospital Revenue Code	250
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$13.42
Rate for Payer: AlohaCare Medicaid	$6.92
Rate for Payer: AlohaCare Medicare	$5.81
Rate for Payer: Cash Price	$8.99
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.72
Rate for Payer: Devoted Health Medicare	$5.81
Rate for Payer: Hawaii Medical Service Association Medicare	$5.81
Rate for Payer: Hawaii Western Management Group Commercial	$13.14
Rate for Payer: Health Management Network Commercial	$11.76
Rate for Payer: Humana Medicare	$5.81
Rate for Payer: Kaiser Permanente Commercial	$12.45
Rate for Payer: Kaiser Permanente Medicaid	$7.05
Rate for Payer: Kaiser Permanente Medicare	$5.81
Rate for Payer: MDX Hawaii PPO	$13.42
Rate for Payer: Ohana Health Plan Medicaid	$5.81
Rate for Payer: Ohana Health Plan Medicare	$5.81
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: UnitedHealthcare Medicare	$5.81
Rate for Payer: University Health Alliance Commercial	$10.08

dilTIAZem 60 mg ER (12-hour) Cap [KMC]

Facility

$13.83

Service Code	NDC 16714055301
Hospital Revenue Code	250
Min. Negotiated Rate	$11.76
Max. Negotiated Rate	$13.42
Rate for Payer: Cash Price	$8.99
Rate for Payer: Health Management Network Commercial	$11.76
Rate for Payer: Kaiser Permanente Commercial	$12.45
Rate for Payer: MDX Hawaii PPO	$13.42

diltiazem 60 mg Tab [KMC]

Facility

$6.27

Service Code	NDC 50228048201
Hospital Revenue Code	250
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$6.08
Rate for Payer: Cash Price	$4.08
Rate for Payer: Health Management Network Commercial	$5.33
Rate for Payer: Kaiser Permanente Commercial	$5.64
Rate for Payer: MDX Hawaii PPO	$6.08

diltiazem 60 mg Tab [KMC]

Facility

$6.27

Service Code	NDC 50228048201
Hospital Revenue Code	250
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$6.08
Rate for Payer: AlohaCare Medicaid	$3.13
Rate for Payer: AlohaCare Medicare	$2.63
Rate for Payer: Cash Price	$4.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.77
Rate for Payer: Devoted Health Medicare	$2.63
Rate for Payer: Hawaii Medical Service Association Medicare	$2.63
Rate for Payer: Hawaii Western Management Group Commercial	$5.96
Rate for Payer: Health Management Network Commercial	$5.33
Rate for Payer: Humana Medicare	$2.63
Rate for Payer: Kaiser Permanente Commercial	$5.64
Rate for Payer: Kaiser Permanente Medicaid	$3.20
Rate for Payer: Kaiser Permanente Medicare	$2.63
Rate for Payer: MDX Hawaii PPO	$6.08
Rate for Payer: Ohana Health Plan Medicaid	$2.63
Rate for Payer: Ohana Health Plan Medicare	$2.63
Rate for Payer: UnitedHealthcare Medicaid	$3.76
Rate for Payer: UnitedHealthcare Medicare	$2.63
Rate for Payer: University Health Alliance Commercial	$4.57

dimethyl fumarate 240 mg DR cap [KMC]

Facility

$595.20

Service Code	NDC 69097032303
Hospital Revenue Code	250
Min. Negotiated Rate	$505.92
Max. Negotiated Rate	$577.34
Rate for Payer: Cash Price	$386.88
Rate for Payer: Health Management Network Commercial	$505.92
Rate for Payer: Kaiser Permanente Commercial	$535.68
Rate for Payer: MDX Hawaii PPO	$577.34

dimethyl fumarate 240 mg DR cap [KMC]

Facility

$595.20

Service Code	NDC 69097032303
Hospital Revenue Code	250
Min. Negotiated Rate	$249.98
Max. Negotiated Rate	$577.34
Rate for Payer: AlohaCare Medicaid	$297.60
Rate for Payer: AlohaCare Medicare	$249.98
Rate for Payer: Cash Price	$386.88
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$547.58
Rate for Payer: Devoted Health Medicare	$249.98
Rate for Payer: Hawaii Medical Service Association Medicare	$249.98
Rate for Payer: Hawaii Western Management Group Commercial	$565.44
Rate for Payer: Health Management Network Commercial	$505.92
Rate for Payer: Humana Medicare	$249.98
Rate for Payer: Kaiser Permanente Commercial	$535.68
Rate for Payer: Kaiser Permanente Medicaid	$303.55
Rate for Payer: Kaiser Permanente Medicare	$249.98
Rate for Payer: MDX Hawaii PPO	$577.34
Rate for Payer: Ohana Health Plan Medicaid	$249.98
Rate for Payer: Ohana Health Plan Medicare	$249.98
Rate for Payer: UnitedHealthcare Medicaid	$357.12
Rate for Payer: UnitedHealthcare Medicare	$249.98
Rate for Payer: University Health Alliance Commercial	$433.84

diphenhydrAMINE 12.5 mg/5 mL Oral Liq [KMC]

Facility

$0.22

Service Code	HCPCS Q0163
Hospital Revenue Code	637
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Management Network Commercial	$0.19
Rate for Payer: Kaiser Permanente Commercial	$0.20
Rate for Payer: MDX Hawaii PPO	$0.21

diphenhydrAMINE 12.5 mg/5 mL Oral Liq [KMC]

Facility

$0.22

Service Code	HCPCS Q0163
Hospital Revenue Code	637
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.21
Rate for Payer: AlohaCare Medicaid	$0.11
Rate for Payer: AlohaCare Medicare	$0.09
Rate for Payer: Cash Price	$0.14
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.20
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Hawaii Medical Service Association Medicare	$0.09
Rate for Payer: Hawaii Western Management Group Commercial	$0.21
Rate for Payer: Health Management Network Commercial	$0.19
Rate for Payer: Humana Medicare	$0.09
Rate for Payer: Kaiser Permanente Commercial	$0.20
Rate for Payer: Kaiser Permanente Medicaid	$0.11
Rate for Payer: Kaiser Permanente Medicare	$0.09
Rate for Payer: MDX Hawaii PPO	$0.21
Rate for Payer: Ohana Health Plan Medicaid	$0.09
Rate for Payer: Ohana Health Plan Medicare	$0.09
Rate for Payer: UnitedHealthcare Medicare	$0.09
Rate for Payer: University Health Alliance Commercial	$0.16

diphenhydrAMINE 25 mg Cap [KMC]

Facility

$3.00

Service Code	HCPCS Q0163
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

diphenhydrAMINE 25 mg Cap [KMC]

Facility

$3.00

Service Code	HCPCS Q0163
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

diphenhydrAMINE 50 mg/mL Inj Sol [KMC]

Facility

$2.68

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$2.60
Rate for Payer: AlohaCare Medicaid	$1.34
Rate for Payer: AlohaCare Medicare	$1.13
Rate for Payer: Cash Price	$1.74
Rate for Payer: Cash Price	$1.74
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.47
Rate for Payer: Devoted Health Medicare	$1.13
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.13
Rate for Payer: Hawaii Western Management Group Commercial	$2.55
Rate for Payer: Health Management Network Commercial	$2.28
Rate for Payer: Humana Medicare	$1.13
Rate for Payer: Kaiser Permanente Commercial	$2.41
Rate for Payer: Kaiser Permanente Medicaid	$1.37
Rate for Payer: Kaiser Permanente Medicare	$1.13
Rate for Payer: MDX Hawaii PPO	$2.60
Rate for Payer: Ohana Health Plan Medicaid	$1.13
Rate for Payer: Ohana Health Plan Medicare	$1.13
Rate for Payer: UnitedHealthcare Medicaid	$1.61
Rate for Payer: UnitedHealthcare Medicare	$1.13
Rate for Payer: University Health Alliance Commercial	$1.95

diphenhydrAMINE 50 mg/mL Inj Sol [KMC]

Facility

$2.68

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$2.60
Rate for Payer: Cash Price	$1.74
Rate for Payer: Health Management Network Commercial	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.41
Rate for Payer: MDX Hawaii PPO	$2.60

DIPHENHYDRAMINE HCL INJECTIO

Professional

Both

$6.00

Service Code	HCPCS J1200
Hospital Revenue Code	636
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$5.10
Rate for Payer: AlohaCare Medicare	$0.69
Rate for Payer: Cash Price	$3.90
Rate for Payer: Cash Price	$3.90
Rate for Payer: Devoted Health Medicare	$0.69
Rate for Payer: Hawaii Medical Service Association Medicare	$0.69
Rate for Payer: Hawaii Western Management Group Commercial	$1.42
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$0.83
Rate for Payer: Kaiser Permanente Medicaid	$0.83
Rate for Payer: Kaiser Permanente Medicare	$0.83
Rate for Payer: Ohana Health Plan Medicare	$0.69
Rate for Payer: UnitedHealthcare Medicare	$0.69

diphenhydramine-zinc 2% Cream [KMC]

Facility

$0.57

Service Code	NDC 45802035803
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.55
Rate for Payer: Cash Price	$0.37
Rate for Payer: Health Management Network Commercial	$0.48
Rate for Payer: Kaiser Permanente Commercial	$0.51
Rate for Payer: MDX Hawaii PPO	$0.55

diphenhydramine-zinc 2% Cream [KMC]

Facility

$0.57

Service Code	NDC 45802035803
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.55
Rate for Payer: AlohaCare Medicaid	$0.29
Rate for Payer: AlohaCare Medicare	$0.24
Rate for Payer: Cash Price	$0.37
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.52
Rate for Payer: Devoted Health Medicare	$0.24
Rate for Payer: Hawaii Medical Service Association Medicare	$0.24
Rate for Payer: Hawaii Western Management Group Commercial	$0.54
Rate for Payer: Health Management Network Commercial	$0.48
Rate for Payer: Humana Medicare	$0.24
Rate for Payer: Kaiser Permanente Commercial	$0.51
Rate for Payer: Kaiser Permanente Medicaid	$0.29
Rate for Payer: Kaiser Permanente Medicare	$0.24
Rate for Payer: MDX Hawaii PPO	$0.55
Rate for Payer: Ohana Health Plan Medicaid	$0.24
Rate for Payer: Ohana Health Plan Medicare	$0.24
Rate for Payer: UnitedHealthcare Medicaid	$0.34
Rate for Payer: UnitedHealthcare Medicare	$0.24
Rate for Payer: University Health Alliance Commercial	$0.42

Know your out-of-pocket cost for care.

All Charges