Kau Hospital

All Charges

Charge

Type

Setting

Price

MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE [134069]

Facility

$168.00

Service Code	HCPCS J1050
Hospital Revenue Code	250
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$103.80
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$167.81

MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE [134069]

Facility

$173.00

Service Code	HCPCS J1050
Hospital Revenue Code	636
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicaid	$84.00
Rate for Payer: AlohaCare Medicare	$52.08
Rate for Payer: AlohaCare Medicare	$53.63
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$103.80
Rate for Payer: Cash Price	$103.80
Rate for Payer: Devoted Health Medicare	$57.12
Rate for Payer: Devoted Health Medicare	$58.82
Rate for Payer: Hawaii Medical Service Association ABD	$0.57
Rate for Payer: Hawaii Medical Service Association ABD	$0.57
Rate for Payer: Hawaii Medical Service Association Medicare	$52.08
Rate for Payer: Hawaii Medical Service Association Medicare	$53.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.57
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Hawaii Western Management Group Commercial	$164.35
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$52.08
Rate for Payer: Humana Medicare	$53.63
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$52.08
Rate for Payer: Kaiser Permanente Medicare	$53.63
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$53.63
Rate for Payer: Ohana Health Plan Medicaid	$52.08
Rate for Payer: Ohana Health Plan Medicare	$52.08
Rate for Payer: Ohana Health Plan Medicare	$53.63
Rate for Payer: UnitedHealthcare Medicaid	$100.80
Rate for Payer: UnitedHealthcare Medicaid	$103.80
Rate for Payer: UnitedHealthcare Medicare	$53.63
Rate for Payer: UnitedHealthcare Medicare	$52.08
Rate for Payer: University Health Alliance Commercial	$122.46
Rate for Payer: University Health Alliance Commercial	$126.10

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$2.00

Service Code	NDC 00555087202
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
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

MEDROXYPROGESTERONE 2.5 MG TABLET [4855]

Facility

$2.00

Service Code	NDC 00555087202
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

MEDULLARY XCHANGE TUBE 355.006

Facility

$356.00

Hospital Revenue Code	272
Min. Negotiated Rate	$110.36
Max. Negotiated Rate	$345.32
Rate for Payer: AlohaCare Medicaid	$178.00
Rate for Payer: AlohaCare Medicare	$110.36
Rate for Payer: Cash Price	$213.60
Rate for Payer: Devoted Health Medicare	$121.04
Rate for Payer: Hawaii Medical Service Association Medicare	$110.36
Rate for Payer: Hawaii Western Management Group Commercial	$338.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Humana Medicare	$110.36
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: Kaiser Permanente Medicaid	$181.56
Rate for Payer: Kaiser Permanente Medicare	$110.36
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: Ohana Health Plan Medicaid	$110.36
Rate for Payer: Ohana Health Plan Medicare	$110.36
Rate for Payer: UnitedHealthcare Medicare	$110.36
Rate for Payer: University Health Alliance Commercial	$259.49

MEDULLARY XCHANGE TUBE 355.006

Facility

$356.00

Hospital Revenue Code	272
Min. Negotiated Rate	$302.60
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$213.60
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: MDX Hawaii PPO	$345.32

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$22.00

Service Code	NDC 69339016016
Hospital Revenue Code	637
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$6.82
Rate for Payer: Cash Price	$13.20
Rate for Payer: Devoted Health Medicare	$7.48
Rate for Payer: Hawaii Medical Service Association Medicare	$6.82
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$6.82
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$6.82
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$6.82
Rate for Payer: Ohana Health Plan Medicare	$6.82
Rate for Payer: UnitedHealthcare Medicare	$6.82
Rate for Payer: University Health Alliance Commercial	$16.04

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$22.00

Service Code	NDC 69339016016
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$21.34

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$20.00

Service Code	NDC 68094006359
Hospital Revenue Code	250
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION [76824]

Facility

$20.00

Service Code	NDC 68094006359
Hospital Revenue Code	637
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$6.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Devoted Health Medicare	$6.80
Rate for Payer: Hawaii Medical Service Association Medicare	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$6.20
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$6.20
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$6.20
Rate for Payer: Ohana Health Plan Medicare	$6.20
Rate for Payer: UnitedHealthcare Medicare	$6.20
Rate for Payer: University Health Alliance Commercial	$14.58

MEGESTROL 40 MG TABLET [4871]

Facility

$6.00

Service Code	NDC 00555060702
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
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

MEGESTROL 40 MG TABLET [4871]

Facility

$6.00

Service Code	NDC 00555060702
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$1.86
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$1.86
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$1.86
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$1.86
Rate for Payer: Ohana Health Plan Medicare	$1.86
Rate for Payer: UnitedHealthcare Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$4.37

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52411000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52411000000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
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

MELATONIN 3 MG TABLET [16830]

Facility

$1.00

Service Code	NDC 61502000000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52415000000
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
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

MELATONIN 3 MG TABLET [16830]

Facility

$1.00

Service Code	NDC 61502000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.31
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.34
Rate for Payer: Hawaii Medical Service Association Medicare	$0.31
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.31
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.31
Rate for Payer: Ohana Health Plan Medicare	$0.31
Rate for Payer: UnitedHealthcare Medicare	$0.31
Rate for Payer: University Health Alliance Commercial	$0.73

MELATONIN 3 MG TABLET [16830]

Facility

$2.00

Service Code	NDC 52415000000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018457
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018411
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018411
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

MEMANTINE 10 MG TABLET [36966]

Facility

$3.00

Service Code	NDC 60687018457
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017311
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017357
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

MEMANTINE 5 MG TABLET [37170]

Facility

$3.00

Service Code	NDC 60687017311
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

Know your out-of-pocket cost for care.

All Charges