Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

folic acid 50 mg / 10 mL Inj Soln [KMC]

Facility

$23.61

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$22.90
Rate for Payer: AlohaCare Medicaid	$11.80
Rate for Payer: AlohaCare Medicare	$9.92
Rate for Payer: Cash Price	$15.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.72
Rate for Payer: Devoted Health Medicare	$9.92
Rate for Payer: Hawaii Medical Service Association Medicare	$9.92
Rate for Payer: Hawaii Western Management Group Commercial	$22.43
Rate for Payer: Health Management Network Commercial	$20.07
Rate for Payer: Humana Medicare	$9.92
Rate for Payer: Kaiser Permanente Commercial	$21.25
Rate for Payer: Kaiser Permanente Medicaid	$12.04
Rate for Payer: Kaiser Permanente Medicare	$9.92
Rate for Payer: MDX Hawaii PPO	$22.90
Rate for Payer: Ohana Health Plan Medicaid	$9.92
Rate for Payer: Ohana Health Plan Medicare	$9.92
Rate for Payer: UnitedHealthcare Medicaid	$14.17
Rate for Payer: UnitedHealthcare Medicare	$9.92
Rate for Payer: University Health Alliance Commercial	$17.21

folic acid 50 mg / 10 mL Inj Soln [KMC]

Facility

$23.61

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$20.07
Max. Negotiated Rate	$22.90
Rate for Payer: Cash Price	$15.35
Rate for Payer: Health Management Network Commercial	$20.07
Rate for Payer: Kaiser Permanente Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$22.90

Food Allergy DLS

Facility

$416.00

Service Code	HCPCS 86003
Hospital Charge Code	422860035
Hospital Revenue Code	302
Min. Negotiated Rate	$353.60
Max. Negotiated Rate	$403.52
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: Kaiser Permanente Commercial	$374.40
Rate for Payer: MDX Hawaii PPO	$403.52

Food Allergy DLS

Facility

$416.00

Service Code	HCPCS 86003
Hospital Charge Code	422860035
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$403.52
Rate for Payer: AlohaCare Medicaid	$208.00
Rate for Payer: AlohaCare Medicare	$174.72
Rate for Payer: Cash Price	$270.40
Rate for Payer: Cash Price	$270.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$382.72
Rate for Payer: Devoted Health Medicare	$174.72
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$174.72
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: Humana Medicare	$174.72
Rate for Payer: Kaiser Permanente Commercial	$374.40
Rate for Payer: Kaiser Permanente Medicaid	$212.16
Rate for Payer: Kaiser Permanente Medicare	$174.72
Rate for Payer: MDX Hawaii PPO	$403.52
Rate for Payer: Ohana Health Plan Medicaid	$174.72
Rate for Payer: Ohana Health Plan Medicare	$174.72
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$174.72
Rate for Payer: University Health Alliance Commercial	$13.51

FOOT COMP MIN 3 VWS

Facility

$369.00

Service Code	HCPCS 73630
Hospital Charge Code	424736300
Hospital Revenue Code	320
Min. Negotiated Rate	$19.08
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	$19.08
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	$19.08
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$62.59

FOOT COMP MIN 3 VWS

Facility

$369.00

Service Code	HCPCS 73630
Hospital Charge Code	424736300
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

FOOT EXAMINATION PERFORMED

Professional

Both

$0.01

Service Code	HCPCS 2028F
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	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
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	$273.13
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

FOOT PROCEDURES WITH CC

Facility

$23,227.96

Service Code	MSDRG 504
Min. Negotiated Rate	$23,227.96
Max. Negotiated Rate	$23,227.96
Rate for Payer: Hawaii Medical Service Association Commercial	$23,227.96

FOOT PROCEDURES WITH MCC

Facility

$23,227.96

Service Code	MSDRG 503
Min. Negotiated Rate	$23,227.96
Max. Negotiated Rate	$23,227.96
Rate for Payer: Hawaii Medical Service Association Commercial	$23,227.96

FOOT PROCEDURES WITHOUT CC/MCC

Facility

$23,227.96

Service Code	MSDRG 505
Min. Negotiated Rate	$23,227.96
Max. Negotiated Rate	$23,227.96
Rate for Payer: Hawaii Medical Service Association Commercial	$23,227.96

FO PF DYN EXT 8 JNT CNCH Occupational

Facility

$207.00

Service Code	HCPCS L3927
Hospital Charge Code	432L39270
Hospital Revenue Code	274
Min. Negotiated Rate	$115.92
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$115.92

FO PF DYN EXT 8 JNT CNCH Occupational

Facility

$207.00

Service Code	HCPCS L3927
Hospital Charge Code	432L39270
Hospital Revenue Code	274
Min. Negotiated Rate	$86.94
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$86.94
Rate for Payer: Cash Price	$134.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$190.44
Rate for Payer: Devoted Health Medicare	$86.94
Rate for Payer: Hawaii Medical Service Association Medicare	$86.94
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$86.94
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$86.94
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$86.94
Rate for Payer: Ohana Health Plan Medicare	$86.94
Rate for Payer: UnitedHealthcare Medicare	$86.94
Rate for Payer: University Health Alliance Commercial	$115.92

FO PF EXT/FLX FINGER SEP Occupational

Facility

$207.00

Service Code	HCPCS L3925
Hospital Charge Code	432L39250
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$86.94
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$190.44
Rate for Payer: Devoted Health Medicare	$86.94
Rate for Payer: Hawaii Medical Service Association Medicare	$86.94
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$86.94
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$86.94
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$86.94
Rate for Payer: Ohana Health Plan Medicare	$86.94
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$86.94
Rate for Payer: University Health Alliance Commercial	$115.92

FO PF EXT/FLX FINGER SEP Occupational

Facility

$207.00

Service Code	HCPCS L3925
Hospital Charge Code	432L39250
Hospital Revenue Code	274
Min. Negotiated Rate	$115.92
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$115.92

FOREARM 2 VWS

Facility

$369.00

Service Code	HCPCS 73090
Hospital Charge Code	424730900
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

FOREARM 2 VWS

Facility

$369.00

Service Code	HCPCS 73090
Hospital Charge Code	424730900
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
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	$17.04
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	$17.04
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$56.28

FOREIGN BODY REMOVAL/PHARYNAX Charge

Facility

$503.00

Service Code	HCPCS 42809
Hospital Charge Code	440428090
Hospital Revenue Code	450
Min. Negotiated Rate	$211.26
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$251.50
Rate for Payer: AlohaCare Medicare	$211.26
Rate for Payer: Cash Price	$326.95
Rate for Payer: Cash Price	$326.95
Rate for Payer: Cash Price	$326.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$462.76
Rate for Payer: Devoted Health Medicare	$211.26
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	$211.26
Rate for Payer: Hawaii Western Management Group Commercial	$477.85
Rate for Payer: Health Management Network Commercial	$427.55
Rate for Payer: Humana Medicare	$211.26
Rate for Payer: Kaiser Permanente Commercial	$452.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$211.26
Rate for Payer: MDX Hawaii PPO	$487.91
Rate for Payer: Ohana Health Plan Medicaid	$211.26
Rate for Payer: Ohana Health Plan Medicare	$211.26
Rate for Payer: UnitedHealthcare Medicare	$211.26
Rate for Payer: University Health Alliance Commercial	$366.64

FOREIGN BODY REMOVAL/PHARYNAX Charge

Facility

$503.00

Service Code	HCPCS 42809
Hospital Charge Code	440428090
Hospital Revenue Code	450
Min. Negotiated Rate	$427.55
Max. Negotiated Rate	$487.91
Rate for Payer: Cash Price	$326.95
Rate for Payer: Health Management Network Commercial	$427.55
Rate for Payer: Kaiser Permanente Commercial	$452.70
Rate for Payer: MDX Hawaii PPO	$487.91

formoterol 20 mcg/2 mL Neb Soln [KMC]

Facility

$44.61

Service Code	HCPCS J7606
Hospital Revenue Code	636
Min. Negotiated Rate	$37.92
Max. Negotiated Rate	$43.27
Rate for Payer: Cash Price	$29.00
Rate for Payer: Health Management Network Commercial	$37.92
Rate for Payer: Kaiser Permanente Commercial	$40.15
Rate for Payer: MDX Hawaii PPO	$43.27

formoterol 20 mcg/2 mL Neb Soln [KMC]

Facility

$44.61

Service Code	HCPCS J7606
Hospital Revenue Code	636
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$43.27
Rate for Payer: AlohaCare Medicaid	$22.30
Rate for Payer: AlohaCare Medicare	$18.74
Rate for Payer: Cash Price	$29.00
Rate for Payer: Cash Price	$29.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$41.04
Rate for Payer: Devoted Health Medicare	$18.74
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.97
Rate for Payer: Hawaii Medical Service Association Medicare	$18.74
Rate for Payer: Hawaii Western Management Group Commercial	$42.38
Rate for Payer: Health Management Network Commercial	$37.92
Rate for Payer: Humana Medicare	$18.74
Rate for Payer: Kaiser Permanente Commercial	$40.15
Rate for Payer: Kaiser Permanente Medicaid	$22.75
Rate for Payer: Kaiser Permanente Medicare	$18.74
Rate for Payer: MDX Hawaii PPO	$43.27
Rate for Payer: Ohana Health Plan Medicaid	$18.74
Rate for Payer: Ohana Health Plan Medicare	$18.74
Rate for Payer: UnitedHealthcare Medicaid	$26.77
Rate for Payer: UnitedHealthcare Medicare	$18.74
Rate for Payer: University Health Alliance Commercial	$32.52

fosfomycin 3 g Oral Powder [KMC]

Facility

$394.00

Service Code	NDC 67877074957
Hospital Revenue Code	250
Min. Negotiated Rate	$334.90
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$256.10
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: MDX Hawaii PPO	$382.18

fosfomycin 3 g Oral Powder [KMC]

Facility

$394.00

Service Code	NDC 67877074957
Hospital Revenue Code	250
Min. Negotiated Rate	$165.48
Max. Negotiated Rate	$382.18
Rate for Payer: AlohaCare Medicaid	$197.00
Rate for Payer: AlohaCare Medicare	$165.48
Rate for Payer: Cash Price	$256.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$362.48
Rate for Payer: Devoted Health Medicare	$165.48
Rate for Payer: Hawaii Medical Service Association Medicare	$165.48
Rate for Payer: Hawaii Western Management Group Commercial	$374.30
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: Humana Medicare	$165.48
Rate for Payer: Kaiser Permanente Commercial	$354.60
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: Kaiser Permanente Medicare	$165.48
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: Ohana Health Plan Medicaid	$165.48
Rate for Payer: Ohana Health Plan Medicare	$165.48
Rate for Payer: UnitedHealthcare Medicaid	$236.40
Rate for Payer: UnitedHealthcare Medicare	$165.48
Rate for Payer: University Health Alliance Commercial	$287.19

fosphenytoin (PE) 500 mg/10 mL Inj Sol [KMC]

Facility

$38.56

Service Code	HCPCS Q2009
Hospital Revenue Code	637
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$37.40
Rate for Payer: AlohaCare Medicaid	$19.28
Rate for Payer: AlohaCare Medicare	$16.20
Rate for Payer: Cash Price	$25.06
Rate for Payer: Cash Price	$25.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$35.48
Rate for Payer: Devoted Health Medicare	$16.20
Rate for Payer: Hawaii Medical Service Association Commercial	$1.66
Rate for Payer: Hawaii Medical Service Association Medicare	$16.20
Rate for Payer: Hawaii Western Management Group Commercial	$36.63
Rate for Payer: Health Management Network Commercial	$32.78
Rate for Payer: Humana Medicare	$16.20
Rate for Payer: Kaiser Permanente Commercial	$34.70
Rate for Payer: Kaiser Permanente Medicaid	$19.67
Rate for Payer: Kaiser Permanente Medicare	$16.20
Rate for Payer: MDX Hawaii PPO	$37.40
Rate for Payer: Ohana Health Plan Medicaid	$16.20
Rate for Payer: Ohana Health Plan Medicare	$16.20
Rate for Payer: UnitedHealthcare Medicare	$16.20
Rate for Payer: University Health Alliance Commercial	$28.11

fosphenytoin (PE) 500 mg/10 mL Inj Sol [KMC]

Facility

$38.56

Service Code	HCPCS Q2009
Hospital Revenue Code	637
Min. Negotiated Rate	$32.78
Max. Negotiated Rate	$37.40
Rate for Payer: Cash Price	$25.06
Rate for Payer: Health Management Network Commercial	$32.78
Rate for Payer: Kaiser Permanente Commercial	$34.70
Rate for Payer: MDX Hawaii PPO	$37.40

FRACTURES OF FEMUR WITH MCC

Facility

$12,182.83

Service Code	MSDRG 533
Min. Negotiated Rate	$12,182.83
Max. Negotiated Rate	$12,182.83
Rate for Payer: Hawaii Medical Service Association Commercial	$12,182.83

Know your out-of-pocket cost for care.

All Charges