Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

ACE BANDAGE 2"

Facility

$3.00

Hospital Charge Code	8003
Hospital Revenue Code	272
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

ACE BANDAGE 2"

Facility

$3.00

Hospital Charge Code	8003
Hospital Revenue Code	272
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

ACE BANDAGE 3"

Facility

$2.00

Hospital Charge Code	8004
Hospital Revenue Code	272
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

ACE BANDAGE 3"

Facility

$2.00

Hospital Charge Code	8004
Hospital Revenue Code	272
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

ACE BANDAGE 4"

Facility

$6.00

Hospital Charge Code	8005
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

ACE BANDAGE 4"

Facility

$6.00

Hospital Charge Code	8005
Hospital Revenue Code	272
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

ACE BANDAGE 6"

Facility

$4.00

Hospital Charge Code	8006
Hospital Revenue Code	272
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

ACE BANDAGE 6"

Facility

$4.00

Hospital Charge Code	8006
Hospital Revenue Code	272
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

ACE INHIBITOR/ARB THERAPY RXD/CURRENTLY TAKEN

Professional

Both

$0.01

Service Code	HCPCS 4010F
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

acetaminophen 1000 mg / 100 mL Inj Soln [KMC]

Facility

$0.40

Service Code	HCPCS J0131
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.39
Rate for Payer: AlohaCare Medicaid	$0.20
Rate for Payer: AlohaCare Medicare	$0.17
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cash Price	$0.26
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.37
Rate for Payer: Devoted Health Medicare	$0.17
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Medicare	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$0.38
Rate for Payer: Health Management Network Commercial	$0.34
Rate for Payer: Humana Medicare	$0.17
Rate for Payer: Kaiser Permanente Commercial	$0.36
Rate for Payer: Kaiser Permanente Medicaid	$0.20
Rate for Payer: Kaiser Permanente Medicare	$0.17
Rate for Payer: MDX Hawaii PPO	$0.39
Rate for Payer: Ohana Health Plan Medicaid	$0.17
Rate for Payer: Ohana Health Plan Medicare	$0.17
Rate for Payer: UnitedHealthcare Medicaid	$0.24
Rate for Payer: UnitedHealthcare Medicare	$0.17
Rate for Payer: University Health Alliance Commercial	$0.29

acetaminophen 1000 mg / 100 mL Inj Soln [KMC]

Facility

$0.40

Service Code	HCPCS J0131
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Management Network Commercial	$0.34
Rate for Payer: Kaiser Permanente Commercial	$0.36
Rate for Payer: MDX Hawaii PPO	$0.39

acetaminophen 120 mg Supp [KMC]

Facility

$3.00

Service Code	NDC 00713011812
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

acetaminophen 120 mg Supp [KMC]

Facility

$3.00

Service Code	NDC 00713011812
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

acetaminophen 160 mg/5 mL Oral Liquid [KMC]

Facility

$0.13

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.13
Rate for Payer: AlohaCare Medicaid	$0.07
Rate for Payer: AlohaCare Medicare	$0.05
Rate for Payer: Cash Price	$0.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.12
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Hawaii Medical Service Association Medicare	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$0.12
Rate for Payer: Health Management Network Commercial	$0.11
Rate for Payer: Humana Medicare	$0.05
Rate for Payer: Kaiser Permanente Commercial	$0.12
Rate for Payer: Kaiser Permanente Medicaid	$0.07
Rate for Payer: Kaiser Permanente Medicare	$0.05
Rate for Payer: MDX Hawaii PPO	$0.13
Rate for Payer: Ohana Health Plan Medicaid	$0.05
Rate for Payer: Ohana Health Plan Medicare	$0.05
Rate for Payer: UnitedHealthcare Medicare	$0.05
Rate for Payer: University Health Alliance Commercial	$0.09

acetaminophen 160 mg/5 mL Oral Liquid [KMC]

Facility

$0.13

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Management Network Commercial	$0.11
Rate for Payer: Kaiser Permanente Commercial	$0.12
Rate for Payer: MDX Hawaii PPO	$0.13

acetaminophen 325 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
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

acetaminophen 325 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
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

acetaminophen 500 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
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

acetaminophen 500 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
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

acetaminophen 650 mg/20.3 mL Susp [KMC]

Facility

$0.39

Service Code	NDC 00121282394
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

acetaminophen 650 mg/20.3 mL Susp [KMC]

Facility

$0.39

Service Code	NDC 00121282394
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

acetaminophen 650 mg Supp [KMC]

Facility

$3.00

Service Code	NDC 00713016512
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

acetaminophen 650 mg Supp [KMC]

Facility

$3.00

Service Code	NDC 00713016512
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

acetaminophen-aspirin-caff 250-250-65 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00536132601
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

acetaminophen-aspirin-caff 250-250-65 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00536132601
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