Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

famotidine 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904719361
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

FB CORNEAL W/SLT LAMP Charge

Facility

$397.00

Service Code	HCPCS 65222
Hospital Charge Code	440652220
Hospital Revenue Code	450
Min. Negotiated Rate	$337.45
Max. Negotiated Rate	$385.09
Rate for Payer: Cash Price	$258.05
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: MDX Hawaii PPO	$385.09

FB CORNEAL W/SLT LAMP Charge

Facility

$397.00

Service Code	HCPCS 65222
Hospital Charge Code	440652220
Hospital Revenue Code	450
Min. Negotiated Rate	$166.74
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$198.50
Rate for Payer: AlohaCare Medicare	$166.74
Rate for Payer: Cash Price	$258.05
Rate for Payer: Cash Price	$258.05
Rate for Payer: Cash Price	$258.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$365.24
Rate for Payer: Devoted Health Medicare	$166.74
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	$166.74
Rate for Payer: Hawaii Western Management Group Commercial	$377.15
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Humana Medicare	$166.74
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$166.74
Rate for Payer: MDX Hawaii PPO	$385.09
Rate for Payer: Ohana Health Plan Medicaid	$166.74
Rate for Payer: Ohana Health Plan Medicare	$166.74
Rate for Payer: UnitedHealthcare Medicare	$166.74
Rate for Payer: University Health Alliance Commercial	$289.37

FB REMOVAL DEEP/COMPLICATED Charge

Facility

$8,867.00

Service Code	HCPCS 20525
Hospital Charge Code	440205250
Hospital Revenue Code	450
Min. Negotiated Rate	$7,536.95
Max. Negotiated Rate	$8,600.99
Rate for Payer: Cash Price	$5,763.55
Rate for Payer: Health Management Network Commercial	$7,536.95
Rate for Payer: Kaiser Permanente Commercial	$7,980.30
Rate for Payer: MDX Hawaii PPO	$8,600.99

FB REMOVAL DEEP/COMPLICATED Charge

Facility

$8,867.00

Service Code	HCPCS 20525
Hospital Charge Code	440205250
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$8,600.99
Rate for Payer: AlohaCare Medicaid	$4,433.50
Rate for Payer: AlohaCare Medicare	$3,724.14
Rate for Payer: Cash Price	$5,763.55
Rate for Payer: Cash Price	$5,763.55
Rate for Payer: Cash Price	$5,763.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8,157.64
Rate for Payer: Devoted Health Medicare	$3,724.14
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	$3,724.14
Rate for Payer: Hawaii Western Management Group Commercial	$8,423.65
Rate for Payer: Health Management Network Commercial	$7,536.95
Rate for Payer: Humana Medicare	$3,724.14
Rate for Payer: Kaiser Permanente Commercial	$7,980.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,724.14
Rate for Payer: MDX Hawaii PPO	$8,600.99
Rate for Payer: Ohana Health Plan Medicaid	$3,724.14
Rate for Payer: Ohana Health Plan Medicare	$3,724.14
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,724.14
Rate for Payer: University Health Alliance Commercial	$6,743.44

FB REMOVAL MUSCLE/TENDON Charge

Facility

$3,272.00

Service Code	HCPCS 20520
Hospital Charge Code	440205200
Hospital Revenue Code	450
Min. Negotiated Rate	$2,781.20
Max. Negotiated Rate	$3,173.84
Rate for Payer: Cash Price	$2,126.80
Rate for Payer: Health Management Network Commercial	$2,781.20
Rate for Payer: Kaiser Permanente Commercial	$2,944.80
Rate for Payer: MDX Hawaii PPO	$3,173.84

FB REMOVAL MUSCLE/TENDON Charge

Facility

$3,272.00

Service Code	HCPCS 20520
Hospital Charge Code	440205200
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,173.84
Rate for Payer: AlohaCare Medicaid	$1,636.00
Rate for Payer: AlohaCare Medicare	$1,374.24
Rate for Payer: Cash Price	$2,126.80
Rate for Payer: Cash Price	$2,126.80
Rate for Payer: Cash Price	$2,126.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3,010.24
Rate for Payer: Devoted Health Medicare	$1,374.24
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	$1,374.24
Rate for Payer: Hawaii Western Management Group Commercial	$3,108.40
Rate for Payer: Health Management Network Commercial	$2,781.20
Rate for Payer: Humana Medicare	$1,374.24
Rate for Payer: Kaiser Permanente Commercial	$2,944.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,374.24
Rate for Payer: MDX Hawaii PPO	$3,173.84
Rate for Payer: Ohana Health Plan Medicaid	$1,374.24
Rate for Payer: Ohana Health Plan Medicare	$1,374.24
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,374.24
Rate for Payer: University Health Alliance Commercial	$2,384.96

FB SCLERAL EMBEDDED Charge

Facility

$397.00

Service Code	HCPCS 65210
Hospital Charge Code	440652100
Hospital Revenue Code	450
Min. Negotiated Rate	$166.74
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$198.50
Rate for Payer: AlohaCare Medicare	$166.74
Rate for Payer: Cash Price	$258.05
Rate for Payer: Cash Price	$258.05
Rate for Payer: Cash Price	$258.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$365.24
Rate for Payer: Devoted Health Medicare	$166.74
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	$166.74
Rate for Payer: Hawaii Western Management Group Commercial	$377.15
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Humana Medicare	$166.74
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$166.74
Rate for Payer: MDX Hawaii PPO	$385.09
Rate for Payer: Ohana Health Plan Medicaid	$166.74
Rate for Payer: Ohana Health Plan Medicare	$166.74
Rate for Payer: UnitedHealthcare Medicare	$166.74
Rate for Payer: University Health Alliance Commercial	$289.37

FB SCLERAL EMBEDDED Charge

Facility

$397.00

Service Code	HCPCS 65210
Hospital Charge Code	440652100
Hospital Revenue Code	450
Min. Negotiated Rate	$337.45
Max. Negotiated Rate	$385.09
Rate for Payer: Cash Price	$258.05
Rate for Payer: Health Management Network Commercial	$337.45
Rate for Payer: Kaiser Permanente Commercial	$357.30
Rate for Payer: MDX Hawaii PPO	$385.09

febuxostat 40 mg Tab [KMC]

Facility

$40.27

Service Code	NDC 72205002830
Hospital Revenue Code	250
Min. Negotiated Rate	$16.91
Max. Negotiated Rate	$39.06
Rate for Payer: AlohaCare Medicaid	$20.14
Rate for Payer: AlohaCare Medicare	$16.91
Rate for Payer: Cash Price	$26.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$37.05
Rate for Payer: Devoted Health Medicare	$16.91
Rate for Payer: Hawaii Medical Service Association Medicare	$16.91
Rate for Payer: Hawaii Western Management Group Commercial	$38.26
Rate for Payer: Health Management Network Commercial	$34.23
Rate for Payer: Humana Medicare	$16.91
Rate for Payer: Kaiser Permanente Commercial	$36.24
Rate for Payer: Kaiser Permanente Medicaid	$20.54
Rate for Payer: Kaiser Permanente Medicare	$16.91
Rate for Payer: MDX Hawaii PPO	$39.06
Rate for Payer: Ohana Health Plan Medicaid	$16.91
Rate for Payer: Ohana Health Plan Medicare	$16.91
Rate for Payer: UnitedHealthcare Medicaid	$24.16
Rate for Payer: UnitedHealthcare Medicare	$16.91
Rate for Payer: University Health Alliance Commercial	$29.35

febuxostat 40 mg Tab [KMC]

Facility

$40.27

Service Code	NDC 72205002830
Hospital Revenue Code	250
Min. Negotiated Rate	$34.23
Max. Negotiated Rate	$39.06
Rate for Payer: Cash Price	$26.18
Rate for Payer: Health Management Network Commercial	$34.23
Rate for Payer: Kaiser Permanente Commercial	$36.24
Rate for Payer: MDX Hawaii PPO	$39.06

febuxostat 80 mg Tab [KMC]

Facility

$34.27

Service Code	NDC 64764067730
Hospital Revenue Code	250
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$33.24
Rate for Payer: AlohaCare Medicaid	$17.14
Rate for Payer: AlohaCare Medicare	$14.39
Rate for Payer: Cash Price	$22.28
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.53
Rate for Payer: Devoted Health Medicare	$14.39
Rate for Payer: Hawaii Medical Service Association Medicare	$14.39
Rate for Payer: Hawaii Western Management Group Commercial	$32.56
Rate for Payer: Health Management Network Commercial	$29.13
Rate for Payer: Humana Medicare	$14.39
Rate for Payer: Kaiser Permanente Commercial	$30.84
Rate for Payer: Kaiser Permanente Medicaid	$17.48
Rate for Payer: Kaiser Permanente Medicare	$14.39
Rate for Payer: MDX Hawaii PPO	$33.24
Rate for Payer: Ohana Health Plan Medicaid	$14.39
Rate for Payer: Ohana Health Plan Medicare	$14.39
Rate for Payer: UnitedHealthcare Medicaid	$20.56
Rate for Payer: UnitedHealthcare Medicare	$14.39
Rate for Payer: University Health Alliance Commercial	$24.98

febuxostat 80 mg Tab [KMC]

Facility

$34.27

Service Code	NDC 64764067730
Hospital Revenue Code	250
Min. Negotiated Rate	$29.13
Max. Negotiated Rate	$33.24
Rate for Payer: Cash Price	$22.28
Rate for Payer: Health Management Network Commercial	$29.13
Rate for Payer: Kaiser Permanente Commercial	$30.84
Rate for Payer: MDX Hawaii PPO	$33.24

FECAL IMPACTION / FB REMOVAL Charge

Facility

$7,251.00

Service Code	HCPCS 45915
Hospital Charge Code	440459150
Hospital Revenue Code	450
Min. Negotiated Rate	$6,163.35
Max. Negotiated Rate	$7,033.47
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Health Management Network Commercial	$6,163.35
Rate for Payer: Kaiser Permanente Commercial	$6,525.90
Rate for Payer: MDX Hawaii PPO	$7,033.47

FECAL IMPACTION / FB REMOVAL Charge

Facility

$7,251.00

Service Code	HCPCS 45915
Hospital Charge Code	440459150
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$7,033.47
Rate for Payer: AlohaCare Medicaid	$3,625.50
Rate for Payer: AlohaCare Medicare	$3,045.42
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6,670.92
Rate for Payer: Devoted Health Medicare	$3,045.42
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	$3,045.42
Rate for Payer: Hawaii Western Management Group Commercial	$6,888.45
Rate for Payer: Health Management Network Commercial	$6,163.35
Rate for Payer: Humana Medicare	$3,045.42
Rate for Payer: Kaiser Permanente Commercial	$6,525.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,045.42
Rate for Payer: MDX Hawaii PPO	$7,033.47
Rate for Payer: Ohana Health Plan Medicaid	$3,045.42
Rate for Payer: Ohana Health Plan Medicare	$3,045.42
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,045.42
Rate for Payer: University Health Alliance Commercial	$5,285.25

FEEDING TUBE 20FR

Facility

$327.00

Hospital Charge Code	8103
Hospital Revenue Code	270
Min. Negotiated Rate	$277.95
Max. Negotiated Rate	$317.19
Rate for Payer: Cash Price	$212.55
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: MDX Hawaii PPO	$317.19

FEEDING TUBE 20FR

Facility

$327.00

Hospital Charge Code	8103
Hospital Revenue Code	270
Min. Negotiated Rate	$137.34
Max. Negotiated Rate	$317.19
Rate for Payer: AlohaCare Medicaid	$163.50
Rate for Payer: AlohaCare Medicare	$137.34
Rate for Payer: Cash Price	$212.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$300.84
Rate for Payer: Devoted Health Medicare	$137.34
Rate for Payer: Hawaii Medical Service Association Medicare	$137.34
Rate for Payer: Hawaii Western Management Group Commercial	$310.65
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Humana Medicare	$137.34
Rate for Payer: Kaiser Permanente Commercial	$294.30
Rate for Payer: Kaiser Permanente Medicaid	$166.77
Rate for Payer: Kaiser Permanente Medicare	$137.34
Rate for Payer: MDX Hawaii PPO	$317.19
Rate for Payer: Ohana Health Plan Medicaid	$137.34
Rate for Payer: Ohana Health Plan Medicare	$137.34
Rate for Payer: UnitedHealthcare Medicare	$137.34
Rate for Payer: University Health Alliance Commercial	$238.35

FEEDING TUBE 22FR

Facility

$338.00

Hospital Charge Code	8104
Hospital Revenue Code	270
Min. Negotiated Rate	$287.30
Max. Negotiated Rate	$327.86
Rate for Payer: Cash Price	$219.70
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: Kaiser Permanente Commercial	$304.20
Rate for Payer: MDX Hawaii PPO	$327.86

FEEDING TUBE 22FR

Facility

$338.00

Hospital Charge Code	8104
Hospital Revenue Code	270
Min. Negotiated Rate	$141.96
Max. Negotiated Rate	$327.86
Rate for Payer: AlohaCare Medicaid	$169.00
Rate for Payer: AlohaCare Medicare	$141.96
Rate for Payer: Cash Price	$219.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$310.96
Rate for Payer: Devoted Health Medicare	$141.96
Rate for Payer: Hawaii Medical Service Association Medicare	$141.96
Rate for Payer: Hawaii Western Management Group Commercial	$321.10
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: Humana Medicare	$141.96
Rate for Payer: Kaiser Permanente Commercial	$304.20
Rate for Payer: Kaiser Permanente Medicaid	$172.38
Rate for Payer: Kaiser Permanente Medicare	$141.96
Rate for Payer: MDX Hawaii PPO	$327.86
Rate for Payer: Ohana Health Plan Medicaid	$141.96
Rate for Payer: Ohana Health Plan Medicare	$141.96
Rate for Payer: UnitedHealthcare Medicare	$141.96
Rate for Payer: University Health Alliance Commercial	$246.37

FEEDING TUBE 24FR

Facility

$18.00

Hospital Charge Code	8105
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

FEEDING TUBE 24FR

Facility

$18.00

Hospital Charge Code	8105
Hospital Revenue Code	270
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$7.56
Rate for Payer: Cash Price	$11.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.56
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$7.56
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$7.56
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$7.56
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$7.56
Rate for Payer: Ohana Health Plan Medicare	$7.56
Rate for Payer: UnitedHealthcare Medicare	$7.56
Rate for Payer: University Health Alliance Commercial	$13.12

FEEDING TUBE W/Y PORT 22FR

Facility

$5.00

Hospital Charge Code	8106
Hospital Revenue Code	272
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

FEEDING TUBE W/Y PORT 22FR

Facility

$5.00

Hospital Charge Code	8106
Hospital Revenue Code	272
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

FEEDING TUBE W/Y PORT 24FR

Facility

$294.00

Hospital Charge Code	8107
Hospital Revenue Code	272
Min. Negotiated Rate	$123.48
Max. Negotiated Rate	$285.18
Rate for Payer: AlohaCare Medicaid	$147.00
Rate for Payer: AlohaCare Medicare	$123.48
Rate for Payer: Cash Price	$191.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$270.48
Rate for Payer: Devoted Health Medicare	$123.48
Rate for Payer: Hawaii Medical Service Association Medicare	$123.48
Rate for Payer: Hawaii Western Management Group Commercial	$279.30
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Humana Medicare	$123.48
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: Kaiser Permanente Medicare	$123.48
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: Ohana Health Plan Medicaid	$123.48
Rate for Payer: Ohana Health Plan Medicare	$123.48
Rate for Payer: UnitedHealthcare Medicare	$123.48
Rate for Payer: University Health Alliance Commercial	$214.30

FEEDING TUBE W/Y PORT 24FR

Facility

$294.00

Hospital Charge Code	8107
Hospital Revenue Code	272
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$191.10
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: MDX Hawaii PPO	$285.18

Know your out-of-pocket cost for care.

All Charges