Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

EZ PAP

Facility

$32.00

Service Code	HCPCS 94640
Hospital Charge Code	429946400
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$323.36
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$13.44
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$29.44
Rate for Payer: Devoted Health Medicare	$13.44
Rate for Payer: Hawaii Medical Service Association Commercial	$323.36
Rate for Payer: Hawaii Medical Service Association Medicare	$13.44
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$13.44
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$13.44
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$13.44
Rate for Payer: Ohana Health Plan Medicare	$13.44
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$13.44
Rate for Payer: University Health Alliance Commercial	$23.32

EZ PAP

Facility

$32.00

Service Code	HCPCS 94640
Hospital Charge Code	429946400
Hospital Revenue Code	410
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$20.80
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04

EZ-PAP

Facility

$176.00

Hospital Charge Code	10002
Hospital Revenue Code	290
Min. Negotiated Rate	$73.92
Max. Negotiated Rate	$170.72
Rate for Payer: AlohaCare Medicaid	$88.00
Rate for Payer: AlohaCare Medicare	$73.92
Rate for Payer: Cash Price	$114.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$161.92
Rate for Payer: Devoted Health Medicare	$73.92
Rate for Payer: Hawaii Medical Service Association Medicare	$73.92
Rate for Payer: Hawaii Western Management Group Commercial	$167.20
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Humana Medicare	$73.92
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: Kaiser Permanente Medicaid	$89.76
Rate for Payer: Kaiser Permanente Medicare	$73.92
Rate for Payer: MDX Hawaii PPO	$170.72
Rate for Payer: Ohana Health Plan Medicaid	$73.92
Rate for Payer: Ohana Health Plan Medicare	$73.92
Rate for Payer: UnitedHealthcare Medicare	$73.92
Rate for Payer: University Health Alliance Commercial	$128.29

EZ-PAP

Facility

$176.00

Hospital Charge Code	10002
Hospital Revenue Code	290
Min. Negotiated Rate	$149.60
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Management Network Commercial	$149.60
Rate for Payer: Kaiser Permanente Commercial	$158.40
Rate for Payer: MDX Hawaii PPO	$170.72

Ez-Pap Subsequent

Facility

$32.00

Service Code	HCPCS 94640
Hospital Charge Code	429946401
Hospital Revenue Code	410
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$20.80
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04

Ez-Pap Subsequent

Facility

$32.00

Service Code	HCPCS 94640
Hospital Charge Code	429946401
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$323.36
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$13.44
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$29.44
Rate for Payer: Devoted Health Medicare	$13.44
Rate for Payer: Hawaii Medical Service Association Commercial	$323.36
Rate for Payer: Hawaii Medical Service Association Medicare	$13.44
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$13.44
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$13.44
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$13.44
Rate for Payer: Ohana Health Plan Medicare	$13.44
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$13.44
Rate for Payer: University Health Alliance Commercial	$23.32

FACE BONES COMP MIN 3 VWS

Facility

$581.00

Service Code	HCPCS 70150
Hospital Charge Code	424701500
Hospital Revenue Code	320
Min. Negotiated Rate	$493.85
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$377.65
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: MDX Hawaii PPO	$563.57

FACE BONES COMP MIN 3 VWS

Facility

$581.00

Service Code	HCPCS 70150
Hospital Charge Code	424701500
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$563.57
Rate for Payer: AlohaCare Medicaid	$290.50
Rate for Payer: AlohaCare Medicare	$244.02
Rate for Payer: Cash Price	$377.65
Rate for Payer: Cash Price	$377.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$534.52
Rate for Payer: Devoted Health Medicare	$244.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.96
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$244.02
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Humana Medicare	$244.02
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: Kaiser Permanente Medicaid	$296.31
Rate for Payer: Kaiser Permanente Medicare	$244.02
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: Ohana Health Plan Medicaid	$244.02
Rate for Payer: Ohana Health Plan Medicare	$244.02
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: UnitedHealthcare Medicare	$244.02
Rate for Payer: University Health Alliance Commercial	$87.39

FACE BONES LESS THAN 3 VWS

Facility

$369.00

Service Code	HCPCS 70140
Hospital Charge Code	424701400
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

FACE BONES LESS THAN 3 VWS

Facility

$369.00

Service Code	HCPCS 70140
Hospital Charge Code	424701400
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
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	$20.40
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	$20.40
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$64.21

Factor VI Activity

Facility

$229.00

Service Code	HCPCS 85230
Hospital Charge Code	422852305
Hospital Revenue Code	305
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$148.85
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: MDX Hawaii PPO	$222.13

Factor VI Activity

Facility

$229.00

Service Code	HCPCS 85230
Hospital Charge Code	422852305
Hospital Revenue Code	305
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$222.13
Rate for Payer: AlohaCare Medicaid	$114.50
Rate for Payer: AlohaCare Medicare	$96.18
Rate for Payer: Cash Price	$148.85
Rate for Payer: Cash Price	$148.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$210.68
Rate for Payer: Devoted Health Medicare	$96.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$24.75
Rate for Payer: Hawaii Medical Service Association Commercial	$22.38
Rate for Payer: Hawaii Medical Service Association Medicare	$96.18
Rate for Payer: Hawaii Western Management Group Commercial	$17.90
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Humana Medicare	$96.18
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: Kaiser Permanente Medicare	$96.18
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: Ohana Health Plan Medicaid	$96.18
Rate for Payer: Ohana Health Plan Medicare	$96.18
Rate for Payer: UnitedHealthcare Medicaid	$24.75
Rate for Payer: UnitedHealthcare Medicare	$96.18
Rate for Payer: University Health Alliance Commercial	$46.29

Factor VII Activity DLS

Facility

$229.00

Service Code	HCPCS 85230
Hospital Charge Code	422852305
Hospital Revenue Code	305
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$222.13
Rate for Payer: AlohaCare Medicaid	$114.50
Rate for Payer: AlohaCare Medicare	$96.18
Rate for Payer: Cash Price	$148.85
Rate for Payer: Cash Price	$148.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$210.68
Rate for Payer: Devoted Health Medicare	$96.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$24.75
Rate for Payer: Hawaii Medical Service Association Commercial	$22.38
Rate for Payer: Hawaii Medical Service Association Medicare	$96.18
Rate for Payer: Hawaii Western Management Group Commercial	$17.90
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Humana Medicare	$96.18
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: Kaiser Permanente Medicaid	$116.79
Rate for Payer: Kaiser Permanente Medicare	$96.18
Rate for Payer: MDX Hawaii PPO	$222.13
Rate for Payer: Ohana Health Plan Medicaid	$96.18
Rate for Payer: Ohana Health Plan Medicare	$96.18
Rate for Payer: UnitedHealthcare Medicaid	$24.75
Rate for Payer: UnitedHealthcare Medicare	$96.18
Rate for Payer: University Health Alliance Commercial	$46.29

Factor VII Activity DLS

Facility

$229.00

Service Code	HCPCS 85230
Hospital Charge Code	422852305
Hospital Revenue Code	305
Min. Negotiated Rate	$194.65
Max. Negotiated Rate	$222.13
Rate for Payer: Cash Price	$148.85
Rate for Payer: Health Management Network Commercial	$194.65
Rate for Payer: Kaiser Permanente Commercial	$206.10
Rate for Payer: MDX Hawaii PPO	$222.13

factor VIII (Alphanate) 2110 unit vial

Facility

$5.56

Service Code	HCPCS J7186
Hospital Revenue Code	636
Min. Negotiated Rate	$4.73
Max. Negotiated Rate	$5.39
Rate for Payer: Cash Price	$3.61
Rate for Payer: Health Management Network Commercial	$4.73
Rate for Payer: Kaiser Permanente Commercial	$5.00
Rate for Payer: MDX Hawaii PPO	$5.39

factor VIII (Alphanate) 2110 unit vial

Facility

$5.56

Service Code	HCPCS J7186
Hospital Revenue Code	636
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$5.39
Rate for Payer: AlohaCare Medicaid	$2.78
Rate for Payer: AlohaCare Medicare	$2.34
Rate for Payer: Cash Price	$3.61
Rate for Payer: Cash Price	$3.61
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.12
Rate for Payer: Devoted Health Medicare	$2.34
Rate for Payer: Hawaii Medical Service Association Commercial	$1.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2.34
Rate for Payer: Hawaii Western Management Group Commercial	$5.28
Rate for Payer: Health Management Network Commercial	$4.73
Rate for Payer: Humana Medicare	$2.34
Rate for Payer: Kaiser Permanente Commercial	$5.00
Rate for Payer: Kaiser Permanente Medicaid	$2.84
Rate for Payer: Kaiser Permanente Medicare	$2.34
Rate for Payer: MDX Hawaii PPO	$5.39
Rate for Payer: Ohana Health Plan Medicaid	$2.34
Rate for Payer: Ohana Health Plan Medicare	$2.34
Rate for Payer: UnitedHealthcare Medicaid	$3.34
Rate for Payer: UnitedHealthcare Medicare	$2.34
Rate for Payer: University Health Alliance Commercial	$4.05

Factor V Leiden Mutation DLS

Facility

$994.00

Service Code	HCPCS 81241
Hospital Charge Code	422812415
Hospital Revenue Code	309
Min. Negotiated Rate	$47.03
Max. Negotiated Rate	$964.18
Rate for Payer: AlohaCare Medicaid	$497.00
Rate for Payer: AlohaCare Medicare	$417.48
Rate for Payer: Cash Price	$646.10
Rate for Payer: Cash Price	$646.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$914.48
Rate for Payer: Devoted Health Medicare	$417.48
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$81.80
Rate for Payer: Hawaii Medical Service Association Commercial	$91.71
Rate for Payer: Hawaii Medical Service Association Medicare	$417.48
Rate for Payer: Hawaii Western Management Group Commercial	$73.37
Rate for Payer: Health Management Network Commercial	$844.90
Rate for Payer: Humana Medicare	$417.48
Rate for Payer: Kaiser Permanente Commercial	$894.60
Rate for Payer: Kaiser Permanente Medicaid	$506.94
Rate for Payer: Kaiser Permanente Medicare	$417.48
Rate for Payer: MDX Hawaii PPO	$964.18
Rate for Payer: Ohana Health Plan Medicaid	$417.48
Rate for Payer: Ohana Health Plan Medicare	$417.48
Rate for Payer: UnitedHealthcare Medicaid	$47.03
Rate for Payer: UnitedHealthcare Medicare	$417.48
Rate for Payer: University Health Alliance Commercial	$154.23

Factor V Leiden Mutation DLS

Facility

$994.00

Service Code	HCPCS 81241
Hospital Charge Code	422812415
Hospital Revenue Code	309
Min. Negotiated Rate	$844.90
Max. Negotiated Rate	$964.18
Rate for Payer: Cash Price	$646.10
Rate for Payer: Health Management Network Commercial	$844.90
Rate for Payer: Kaiser Permanente Commercial	$894.60
Rate for Payer: MDX Hawaii PPO	$964.18

FALLS PLAN OF CARE DOCUMENTED

Professional

Both

$0.01

Service Code	HCPCS 0518F
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

famotidine 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904552987
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

famotidine 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904552987
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

famotidine 20 mg/2 mL IV Soln [KMC]

Facility

$2.16

Service Code	HCPCS S0028
Hospital Revenue Code	637
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$2.10
Rate for Payer: AlohaCare Medicaid	$1.08
Rate for Payer: AlohaCare Medicare	$0.91
Rate for Payer: Cash Price	$1.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.99
Rate for Payer: Devoted Health Medicare	$0.91
Rate for Payer: Hawaii Medical Service Association Medicare	$0.91
Rate for Payer: Hawaii Western Management Group Commercial	$2.05
Rate for Payer: Health Management Network Commercial	$1.84
Rate for Payer: Humana Medicare	$0.91
Rate for Payer: Kaiser Permanente Commercial	$1.94
Rate for Payer: Kaiser Permanente Medicaid	$1.10
Rate for Payer: Kaiser Permanente Medicare	$0.91
Rate for Payer: MDX Hawaii PPO	$2.10
Rate for Payer: Ohana Health Plan Medicaid	$0.91
Rate for Payer: Ohana Health Plan Medicare	$0.91
Rate for Payer: UnitedHealthcare Medicare	$0.91
Rate for Payer: University Health Alliance Commercial	$1.57

famotidine 20 mg/2 mL IV Soln [KMC]

Facility

$2.16

Service Code	HCPCS S0028
Hospital Revenue Code	637
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.10
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Management Network Commercial	$1.84
Rate for Payer: Kaiser Permanente Commercial	$1.94
Rate for Payer: MDX Hawaii PPO	$2.10

famotidine 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904719361
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