Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

dornase alfa 2.5 mg/2.5 mL Soln [KMC]

Facility

$172.81

Service Code	HCPCS J7639
Hospital Revenue Code	636
Min. Negotiated Rate	$55.16
Max. Negotiated Rate	$167.63
Rate for Payer: AlohaCare Medicaid	$86.41
Rate for Payer: AlohaCare Medicare	$72.58
Rate for Payer: Cash Price	$112.33
Rate for Payer: Cash Price	$112.33
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$158.99
Rate for Payer: Devoted Health Medicare	$72.58
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$55.16
Rate for Payer: Hawaii Medical Service Association Medicare	$72.58
Rate for Payer: Hawaii Western Management Group Commercial	$164.17
Rate for Payer: Health Management Network Commercial	$146.89
Rate for Payer: Humana Medicare	$72.58
Rate for Payer: Kaiser Permanente Commercial	$155.53
Rate for Payer: Kaiser Permanente Medicaid	$88.13
Rate for Payer: Kaiser Permanente Medicare	$72.58
Rate for Payer: MDX Hawaii PPO	$167.63
Rate for Payer: Ohana Health Plan Medicaid	$72.58
Rate for Payer: Ohana Health Plan Medicare	$72.58
Rate for Payer: UnitedHealthcare Medicaid	$103.69
Rate for Payer: UnitedHealthcare Medicare	$72.58
Rate for Payer: University Health Alliance Commercial	$125.96

dorzolamide ophthalmic 2% Sol [KMC]

Facility

$26.72

Service Code	NDC 42571014126
Hospital Revenue Code	250
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$25.92
Rate for Payer: AlohaCare Medicaid	$13.36
Rate for Payer: AlohaCare Medicare	$11.22
Rate for Payer: Cash Price	$17.37
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$24.58
Rate for Payer: Devoted Health Medicare	$11.22
Rate for Payer: Hawaii Medical Service Association Medicare	$11.22
Rate for Payer: Hawaii Western Management Group Commercial	$25.38
Rate for Payer: Health Management Network Commercial	$22.71
Rate for Payer: Humana Medicare	$11.22
Rate for Payer: Kaiser Permanente Commercial	$24.05
Rate for Payer: Kaiser Permanente Medicaid	$13.63
Rate for Payer: Kaiser Permanente Medicare	$11.22
Rate for Payer: MDX Hawaii PPO	$25.92
Rate for Payer: Ohana Health Plan Medicaid	$11.22
Rate for Payer: Ohana Health Plan Medicare	$11.22
Rate for Payer: UnitedHealthcare Medicaid	$16.03
Rate for Payer: UnitedHealthcare Medicare	$11.22
Rate for Payer: University Health Alliance Commercial	$19.48

dorzolamide ophthalmic 2% Sol [KMC]

Facility

$26.72

Service Code	NDC 42571014126
Hospital Revenue Code	250
Min. Negotiated Rate	$22.71
Max. Negotiated Rate	$25.92
Rate for Payer: Cash Price	$17.37
Rate for Payer: Health Management Network Commercial	$22.71
Rate for Payer: Kaiser Permanente Commercial	$24.05
Rate for Payer: MDX Hawaii PPO	$25.92

dorzolamide-timolol ophthalmic 2.23%-0.68% Sol [KMC]

Facility

$27.00

Service Code	NDC 24208048610
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

dorzolamide-timolol ophthalmic 2.23%-0.68% Sol [KMC]

Facility

$27.00

Service Code	NDC 24208048610
Hospital Revenue Code	250
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$26.19
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$11.34
Rate for Payer: Cash Price	$17.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$24.84
Rate for Payer: Devoted Health Medicare	$11.34
Rate for Payer: Hawaii Medical Service Association Medicare	$11.34
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$11.34
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$11.34
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$11.34
Rate for Payer: Ohana Health Plan Medicare	$11.34
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: UnitedHealthcare Medicare	$11.34
Rate for Payer: University Health Alliance Commercial	$19.68

doxazosin 1 mg Tab

Facility

$5.39

Service Code	NDC 68382078301
Hospital Revenue Code	250
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$5.23
Rate for Payer: Cash Price	$3.50
Rate for Payer: Health Management Network Commercial	$4.58
Rate for Payer: Kaiser Permanente Commercial	$4.85
Rate for Payer: MDX Hawaii PPO	$5.23

doxazosin 1 mg Tab

Facility

$5.39

Service Code	NDC 68382078301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$5.23
Rate for Payer: AlohaCare Medicaid	$2.69
Rate for Payer: AlohaCare Medicare	$2.26
Rate for Payer: Cash Price	$3.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.96
Rate for Payer: Devoted Health Medicare	$2.26
Rate for Payer: Hawaii Medical Service Association Medicare	$2.26
Rate for Payer: Hawaii Western Management Group Commercial	$5.12
Rate for Payer: Health Management Network Commercial	$4.58
Rate for Payer: Humana Medicare	$2.26
Rate for Payer: Kaiser Permanente Commercial	$4.85
Rate for Payer: Kaiser Permanente Medicaid	$2.75
Rate for Payer: Kaiser Permanente Medicare	$2.26
Rate for Payer: MDX Hawaii PPO	$5.23
Rate for Payer: Ohana Health Plan Medicaid	$2.26
Rate for Payer: Ohana Health Plan Medicare	$2.26
Rate for Payer: UnitedHealthcare Medicaid	$3.23
Rate for Payer: UnitedHealthcare Medicare	$2.26
Rate for Payer: University Health Alliance Commercial	$3.93

doxazosin 2 mg Tab [KMC]

Facility

$5.39

Service Code	NDC 67253038110
Hospital Revenue Code	250
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$5.23
Rate for Payer: AlohaCare Medicaid	$2.69
Rate for Payer: AlohaCare Medicare	$2.26
Rate for Payer: Cash Price	$3.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.96
Rate for Payer: Devoted Health Medicare	$2.26
Rate for Payer: Hawaii Medical Service Association Medicare	$2.26
Rate for Payer: Hawaii Western Management Group Commercial	$5.12
Rate for Payer: Health Management Network Commercial	$4.58
Rate for Payer: Humana Medicare	$2.26
Rate for Payer: Kaiser Permanente Commercial	$4.85
Rate for Payer: Kaiser Permanente Medicaid	$2.75
Rate for Payer: Kaiser Permanente Medicare	$2.26
Rate for Payer: MDX Hawaii PPO	$5.23
Rate for Payer: Ohana Health Plan Medicaid	$2.26
Rate for Payer: Ohana Health Plan Medicare	$2.26
Rate for Payer: UnitedHealthcare Medicaid	$3.23
Rate for Payer: UnitedHealthcare Medicare	$2.26
Rate for Payer: University Health Alliance Commercial	$3.93

doxazosin 2 mg Tab [KMC]

Facility

$5.39

Service Code	NDC 67253038110
Hospital Revenue Code	250
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$5.23
Rate for Payer: Cash Price	$3.50
Rate for Payer: Health Management Network Commercial	$4.58
Rate for Payer: Kaiser Permanente Commercial	$4.85
Rate for Payer: MDX Hawaii PPO	$5.23

doxepin 10 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 69238116609
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

doxepin 10 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 69238116609
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

doxepin 25 mg Cap [KMC]

Facility

$3.30

Service Code	NDC 16714013301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Management Network Commercial	$2.81
Rate for Payer: Kaiser Permanente Commercial	$2.97
Rate for Payer: MDX Hawaii PPO	$3.20

doxepin 25 mg Cap [KMC]

Facility

$3.30

Service Code	NDC 16714013301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$3.20
Rate for Payer: AlohaCare Medicaid	$1.65
Rate for Payer: AlohaCare Medicare	$1.39
Rate for Payer: Cash Price	$2.14
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.04
Rate for Payer: Devoted Health Medicare	$1.39
Rate for Payer: Hawaii Medical Service Association Medicare	$1.39
Rate for Payer: Hawaii Western Management Group Commercial	$3.13
Rate for Payer: Health Management Network Commercial	$2.81
Rate for Payer: Humana Medicare	$1.39
Rate for Payer: Kaiser Permanente Commercial	$2.97
Rate for Payer: Kaiser Permanente Medicaid	$1.68
Rate for Payer: Kaiser Permanente Medicare	$1.39
Rate for Payer: MDX Hawaii PPO	$3.20
Rate for Payer: Ohana Health Plan Medicaid	$1.39
Rate for Payer: Ohana Health Plan Medicare	$1.39
Rate for Payer: UnitedHealthcare Medicaid	$1.98
Rate for Payer: UnitedHealthcare Medicare	$1.39
Rate for Payer: University Health Alliance Commercial	$2.41

doxepin 3 mg Tab [KMC]

Facility

$65.18

Service Code	NDC 44183010330
Hospital Revenue Code	250
Min. Negotiated Rate	$27.38
Max. Negotiated Rate	$63.22
Rate for Payer: AlohaCare Medicaid	$32.59
Rate for Payer: AlohaCare Medicare	$27.38
Rate for Payer: Cash Price	$42.37
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$59.97
Rate for Payer: Devoted Health Medicare	$27.38
Rate for Payer: Hawaii Medical Service Association Medicare	$27.38
Rate for Payer: Hawaii Western Management Group Commercial	$61.92
Rate for Payer: Health Management Network Commercial	$55.40
Rate for Payer: Humana Medicare	$27.38
Rate for Payer: Kaiser Permanente Commercial	$58.66
Rate for Payer: Kaiser Permanente Medicaid	$33.24
Rate for Payer: Kaiser Permanente Medicare	$27.38
Rate for Payer: MDX Hawaii PPO	$63.22
Rate for Payer: Ohana Health Plan Medicaid	$27.38
Rate for Payer: Ohana Health Plan Medicare	$27.38
Rate for Payer: UnitedHealthcare Medicaid	$39.11
Rate for Payer: UnitedHealthcare Medicare	$27.38
Rate for Payer: University Health Alliance Commercial	$47.51

doxepin 3 mg Tab [KMC]

Facility

$65.18

Service Code	NDC 44183010330
Hospital Revenue Code	250
Min. Negotiated Rate	$55.40
Max. Negotiated Rate	$63.22
Rate for Payer: Cash Price	$42.37
Rate for Payer: Health Management Network Commercial	$55.40
Rate for Payer: Kaiser Permanente Commercial	$58.66
Rate for Payer: MDX Hawaii PPO	$63.22

doxepin 50 mg Cap [KMC]

Facility

$4.72

Service Code	NDC 16714013401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$4.58
Rate for Payer: Cash Price	$3.07
Rate for Payer: Health Management Network Commercial	$4.01
Rate for Payer: Kaiser Permanente Commercial	$4.25
Rate for Payer: MDX Hawaii PPO	$4.58

doxepin 50 mg Cap [KMC]

Facility

$4.72

Service Code	NDC 16714013401
Hospital Revenue Code	250
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$4.58
Rate for Payer: AlohaCare Medicaid	$2.36
Rate for Payer: AlohaCare Medicare	$1.98
Rate for Payer: Cash Price	$3.07
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.34
Rate for Payer: Devoted Health Medicare	$1.98
Rate for Payer: Hawaii Medical Service Association Medicare	$1.98
Rate for Payer: Hawaii Western Management Group Commercial	$4.48
Rate for Payer: Health Management Network Commercial	$4.01
Rate for Payer: Humana Medicare	$1.98
Rate for Payer: Kaiser Permanente Commercial	$4.25
Rate for Payer: Kaiser Permanente Medicaid	$2.41
Rate for Payer: Kaiser Permanente Medicare	$1.98
Rate for Payer: MDX Hawaii PPO	$4.58
Rate for Payer: Ohana Health Plan Medicaid	$1.98
Rate for Payer: Ohana Health Plan Medicare	$1.98
Rate for Payer: UnitedHealthcare Medicaid	$2.83
Rate for Payer: UnitedHealthcare Medicare	$1.98
Rate for Payer: University Health Alliance Commercial	$3.44

doxepin 6 mg Tab [KMC]

Facility

$69.01

Service Code	NDC 64380020401
Hospital Revenue Code	250
Min. Negotiated Rate	$28.98
Max. Negotiated Rate	$66.94
Rate for Payer: AlohaCare Medicaid	$34.51
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.49
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$65.56
Rate for Payer: Health Management Network Commercial	$58.66
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.11
Rate for Payer: Kaiser Permanente Medicaid	$35.20
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.94
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$41.41
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$50.30

doxepin 6 mg Tab [KMC]

Facility

$69.01

Service Code	NDC 64380020401
Hospital Revenue Code	250
Min. Negotiated Rate	$58.66
Max. Negotiated Rate	$66.94
Rate for Payer: Cash Price	$44.86
Rate for Payer: Health Management Network Commercial	$58.66
Rate for Payer: Kaiser Permanente Commercial	$62.11
Rate for Payer: MDX Hawaii PPO	$66.94

doxycycline 100 mg REC injection [KMC]

Facility

$115.97

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$48.71
Max. Negotiated Rate	$112.49
Rate for Payer: AlohaCare Medicaid	$57.98
Rate for Payer: AlohaCare Medicare	$48.71
Rate for Payer: Cash Price	$75.38
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$106.69
Rate for Payer: Devoted Health Medicare	$48.71
Rate for Payer: Hawaii Medical Service Association Medicare	$48.71
Rate for Payer: Hawaii Western Management Group Commercial	$110.17
Rate for Payer: Health Management Network Commercial	$98.57
Rate for Payer: Humana Medicare	$48.71
Rate for Payer: Kaiser Permanente Commercial	$104.37
Rate for Payer: Kaiser Permanente Medicaid	$59.14
Rate for Payer: Kaiser Permanente Medicare	$48.71
Rate for Payer: MDX Hawaii PPO	$112.49
Rate for Payer: Ohana Health Plan Medicaid	$48.71
Rate for Payer: Ohana Health Plan Medicare	$48.71
Rate for Payer: UnitedHealthcare Medicaid	$69.58
Rate for Payer: UnitedHealthcare Medicare	$48.71
Rate for Payer: University Health Alliance Commercial	$84.53

doxycycline 100 mg REC injection [KMC]

Facility

$115.97

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$98.57
Max. Negotiated Rate	$112.49
Rate for Payer: Cash Price	$75.38
Rate for Payer: Health Management Network Commercial	$98.57
Rate for Payer: Kaiser Permanente Commercial	$104.37
Rate for Payer: MDX Hawaii PPO	$112.49

doxycycline monohydrate 100 mg Cap [KMC]

Facility

$8.53

Service Code	NDC 62332025050
Hospital Revenue Code	250
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$8.27
Rate for Payer: Cash Price	$5.54
Rate for Payer: Health Management Network Commercial	$7.25
Rate for Payer: Kaiser Permanente Commercial	$7.68
Rate for Payer: MDX Hawaii PPO	$8.27

doxycycline monohydrate 100 mg Cap [KMC]

Facility

$8.53

Service Code	NDC 62332025050
Hospital Revenue Code	250
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$8.27
Rate for Payer: AlohaCare Medicaid	$4.26
Rate for Payer: AlohaCare Medicare	$3.58
Rate for Payer: Cash Price	$5.54
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.85
Rate for Payer: Devoted Health Medicare	$3.58
Rate for Payer: Hawaii Medical Service Association Medicare	$3.58
Rate for Payer: Hawaii Western Management Group Commercial	$8.10
Rate for Payer: Health Management Network Commercial	$7.25
Rate for Payer: Humana Medicare	$3.58
Rate for Payer: Kaiser Permanente Commercial	$7.68
Rate for Payer: Kaiser Permanente Medicaid	$4.35
Rate for Payer: Kaiser Permanente Medicare	$3.58
Rate for Payer: MDX Hawaii PPO	$8.27
Rate for Payer: Ohana Health Plan Medicaid	$3.58
Rate for Payer: Ohana Health Plan Medicare	$3.58
Rate for Payer: UnitedHealthcare Medicaid	$5.12
Rate for Payer: UnitedHealthcare Medicare	$3.58
Rate for Payer: University Health Alliance Commercial	$6.22

doxylamine 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 41167000607
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

doxylamine 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 41167000607
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

Know your out-of-pocket cost for care.

All Charges