Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

EXERCISE EQT Occupational

Facility

$5.00

Service Code	HCPCS A9300 GO
Hospital Charge Code	426A93000
Hospital Revenue Code	430
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

EXERCISE EQT Occupational

Facility

$5.00

Service Code	HCPCS A9300 GO
Hospital Charge Code	426A93000
Hospital Revenue Code	430
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

EXERCISE EQT Physical

Facility

$5.00

Service Code	HCPCS A9300 GP
Hospital Charge Code	432A93000
Hospital Revenue Code	420
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

EXERCISE EQT Physical

Facility

$5.00

Service Code	HCPCS A9300 GP
Hospital Charge Code	432A93000
Hospital Revenue Code	420
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

EXERCISE EQUIPMENT

Professional

Both

$5.00

Service Code	HCPCS A9300
Hospital Revenue Code	521
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
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	$4.25
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
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

EXPLORATION PENETRATING EXTREMITY WOUND CHARGE

Facility

$4,314.00

Service Code	HCPCS 20103
Hospital Charge Code	440201030
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,184.58
Rate for Payer: AlohaCare Medicaid	$2,157.00
Rate for Payer: AlohaCare Medicare	$1,811.88
Rate for Payer: Cash Price	$2,804.10
Rate for Payer: Cash Price	$2,804.10
Rate for Payer: Cash Price	$2,804.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3,968.88
Rate for Payer: Devoted Health Medicare	$1,811.88
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,811.88
Rate for Payer: Hawaii Western Management Group Commercial	$4,098.30
Rate for Payer: Health Management Network Commercial	$3,666.90
Rate for Payer: Humana Medicare	$1,811.88
Rate for Payer: Kaiser Permanente Commercial	$3,882.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,811.88
Rate for Payer: MDX Hawaii PPO	$4,184.58
Rate for Payer: Ohana Health Plan Medicaid	$1,811.88
Rate for Payer: Ohana Health Plan Medicare	$1,811.88
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,811.88
Rate for Payer: University Health Alliance Commercial	$3,144.47

EXPLORATION PENETRATING EXTREMITY WOUND CHARGE

Facility

$4,314.00

Service Code	HCPCS 20103
Hospital Charge Code	440201030
Hospital Revenue Code	450
Min. Negotiated Rate	$3,666.90
Max. Negotiated Rate	$4,184.58
Rate for Payer: Cash Price	$2,804.10
Rate for Payer: Health Management Network Commercial	$3,666.90
Rate for Payer: Kaiser Permanente Commercial	$3,882.60
Rate for Payer: MDX Hawaii PPO	$4,184.58

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$61,625.20

Service Code	MSDRG 933
Min. Negotiated Rate	$61,625.20
Max. Negotiated Rate	$61,625.20
Rate for Payer: Hawaii Medical Service Association Commercial	$61,625.20

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$382,502.88

Service Code	MSDRG 927
Min. Negotiated Rate	$382,502.88
Max. Negotiated Rate	$382,502.88
Rate for Payer: Hawaii Medical Service Association Commercial	$382,502.88

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$45,650.05

Service Code	MSDRG 982
Min. Negotiated Rate	$45,650.05
Max. Negotiated Rate	$45,650.05
Rate for Payer: Hawaii Medical Service Association Commercial	$45,650.05

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$76,510.06

Service Code	MSDRG 981
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$30,291.16

Service Code	MSDRG 983
Min. Negotiated Rate	$30,291.16
Max. Negotiated Rate	$30,291.16
Rate for Payer: Hawaii Medical Service Association Commercial	$30,291.16

EXTERNAL ECG REC>7D<15D RECORDING

Professional

Both

$39.00

Service Code	HCPCS 93246
Hospital Revenue Code	730
Min. Negotiated Rate	$13.11
Max. Negotiated Rate	$33.15
Rate for Payer: AlohaCare Medicaid	$13.57
Rate for Payer: AlohaCare Medicare	$13.11
Rate for Payer: Cash Price	$25.35
Rate for Payer: Cash Price	$25.35
Rate for Payer: Devoted Health Medicare	$13.11
Rate for Payer: Hawaii Medical Service Association Medicare	$13.11
Rate for Payer: Hawaii Western Management Group Commercial	$17.39
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$15.73
Rate for Payer: Kaiser Permanente Medicaid	$15.73
Rate for Payer: Kaiser Permanente Medicare	$15.73
Rate for Payer: Ohana Health Plan Medicaid	$13.57
Rate for Payer: Ohana Health Plan Medicare	$13.11
Rate for Payer: UnitedHealthcare Medicaid	$13.57
Rate for Payer: UnitedHealthcare Medicare	$13.11

EXTRACRANIAL PROCEDURES WITH CC

Facility

$54,135.37

Service Code	MSDRG 038
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$54,135.37
Rate for Payer: Hawaii Medical Service Association Commercial	$54,135.37
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$65,038.29

Service Code	MSDRG 037
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$65,038.29
Rate for Payer: Hawaii Medical Service Association Commercial	$65,038.29
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$42,142.16

Service Code	MSDRG 039
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$42,142.16
Rate for Payer: Hawaii Medical Service Association Commercial	$42,142.16
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$17,800.20

Service Code	MSDRG 115
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$17,800.20
Rate for Payer: Hawaii Medical Service Association Commercial	$17,800.20
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$271,980.45

Service Code	MSDRG 790
Min. Negotiated Rate	$271,980.45
Max. Negotiated Rate	$271,980.45
Rate for Payer: Hawaii Medical Service Association Commercial	$271,980.45

EYE DETECT FB

Facility

$369.00

Service Code	HCPCS 70030
Hospital Charge Code	424700300
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

EYE DETECT FB

Facility

$369.00

Service Code	HCPCS 70030
Hospital Charge Code	424700300
Hospital Revenue Code	320
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$13.91
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$13.91
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$55.37

EYEPADS 2-18"X2-5/8"

Facility

$36.00

Hospital Charge Code	8099
Hospital Revenue Code	270
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$15.12
Rate for Payer: Cash Price	$23.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.12
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Hawaii Medical Service Association Medicare	$15.12
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$15.12
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$15.12
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$15.12
Rate for Payer: Ohana Health Plan Medicare	$15.12
Rate for Payer: UnitedHealthcare Medicare	$15.12
Rate for Payer: University Health Alliance Commercial	$26.24

EYEPADS 2-18"X2-5/8"

Facility

$36.00

Hospital Charge Code	8099
Hospital Revenue Code	270
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

Eye Relief Ophth irrigation, extraocular Sol [KMC]

Facility

$3.19

Service Code	NDC 00065053001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$3.09
Rate for Payer: AlohaCare Medicaid	$1.59
Rate for Payer: AlohaCare Medicare	$1.34
Rate for Payer: Cash Price	$2.07
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.93
Rate for Payer: Devoted Health Medicare	$1.34
Rate for Payer: Hawaii Medical Service Association Medicare	$1.34
Rate for Payer: Hawaii Western Management Group Commercial	$3.03
Rate for Payer: Health Management Network Commercial	$2.71
Rate for Payer: Humana Medicare	$1.34
Rate for Payer: Kaiser Permanente Commercial	$2.87
Rate for Payer: Kaiser Permanente Medicaid	$1.63
Rate for Payer: Kaiser Permanente Medicare	$1.34
Rate for Payer: MDX Hawaii PPO	$3.09
Rate for Payer: Ohana Health Plan Medicaid	$1.34
Rate for Payer: Ohana Health Plan Medicare	$1.34
Rate for Payer: UnitedHealthcare Medicaid	$1.91
Rate for Payer: UnitedHealthcare Medicare	$1.34
Rate for Payer: University Health Alliance Commercial	$2.33

Eye Relief Ophth irrigation, extraocular Sol [KMC]

Facility

$3.19

Service Code	NDC 00065053001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$3.09
Rate for Payer: Cash Price	$2.07
Rate for Payer: Health Management Network Commercial	$2.71
Rate for Payer: Kaiser Permanente Commercial	$2.87
Rate for Payer: MDX Hawaii PPO	$3.09

ezetimibe 10 mg Tab [KMC]

Facility

$45.14

Service Code	NDC 69238115403
Hospital Revenue Code	250
Min. Negotiated Rate	$38.37
Max. Negotiated Rate	$43.79
Rate for Payer: Cash Price	$29.34
Rate for Payer: Health Management Network Commercial	$38.37
Rate for Payer: Kaiser Permanente Commercial	$40.63
Rate for Payer: MDX Hawaii PPO	$43.79

Know your out-of-pocket cost for care.

All Charges