Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

FRACTURES OF FEMUR WITHOUT MCC

Facility

$12,182.83

Service Code	MSDRG 534
Min. Negotiated Rate	$12,182.83
Max. Negotiated Rate	$12,182.83
Rate for Payer: Hawaii Medical Service Association Commercial	$12,182.83

FRACTURES OF HIP AND PELVIS WITH MCC

Facility

$17,444.67

Service Code	MSDRG 535
Min. Negotiated Rate	$17,444.67
Max. Negotiated Rate	$17,444.67
Rate for Payer: Hawaii Medical Service Association Commercial	$17,444.67

FRACTURES OF HIP AND PELVIS WITHOUT MCC

Facility

$17,444.67

Service Code	MSDRG 536
Min. Negotiated Rate	$17,444.67
Max. Negotiated Rate	$17,444.67
Rate for Payer: Hawaii Medical Service Association Commercial	$17,444.67

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC

Facility

$13,154.61

Service Code	MSDRG 562
Min. Negotiated Rate	$13,154.61
Max. Negotiated Rate	$13,154.61
Rate for Payer: Hawaii Medical Service Association Commercial	$13,154.61

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC

Facility

$13,154.61

Service Code	MSDRG 563
Min. Negotiated Rate	$13,154.61
Max. Negotiated Rate	$13,154.61
Rate for Payer: Hawaii Medical Service Association Commercial	$13,154.61

FRACTURE TX FEMUR, PROX END/NECK W/O MAN (PRO FEE)

Facility

$887.00

Service Code	HCPCS 27230
Hospital Charge Code	440272300
Hospital Revenue Code	450
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$576.55
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

FRACTURE TX FEMUR, PROX END/NECK W/O MAN (PRO FEE)

Facility

$887.00

Service Code	HCPCS 27230
Hospital Charge Code	440272300
Hospital Revenue Code	450
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$372.54
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$816.04
Rate for Payer: Devoted Health Medicare	$372.54
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	$372.54
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$372.54
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$372.54
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$372.54
Rate for Payer: Ohana Health Plan Medicare	$372.54
Rate for Payer: UnitedHealthcare Medicare	$372.54
Rate for Payer: University Health Alliance Commercial	$646.53

Free T4

Facility

$82.00

Service Code	HCPCS 84439
Hospital Charge Code	422844390
Hospital Revenue Code	301
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$53.30
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: MDX Hawaii PPO	$79.54

Free T4

Facility

$82.00

Service Code	HCPCS 84439
Hospital Charge Code	422844390
Hospital Revenue Code	301
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$79.54
Rate for Payer: AlohaCare Medicaid	$41.00
Rate for Payer: AlohaCare Medicare	$34.44
Rate for Payer: Cash Price	$53.30
Rate for Payer: Cash Price	$53.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$75.44
Rate for Payer: Devoted Health Medicare	$34.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$12.46
Rate for Payer: Hawaii Medical Service Association Commercial	$11.28
Rate for Payer: Hawaii Medical Service Association Medicare	$34.44
Rate for Payer: Hawaii Western Management Group Commercial	$9.02
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Humana Medicare	$34.44
Rate for Payer: Kaiser Permanente Commercial	$73.80
Rate for Payer: Kaiser Permanente Medicaid	$41.82
Rate for Payer: Kaiser Permanente Medicare	$34.44
Rate for Payer: MDX Hawaii PPO	$79.54
Rate for Payer: Ohana Health Plan Medicaid	$34.44
Rate for Payer: Ohana Health Plan Medicare	$34.44
Rate for Payer: UnitedHealthcare Medicaid	$12.46
Rate for Payer: UnitedHealthcare Medicare	$34.44
Rate for Payer: University Health Alliance Commercial	$23.31

FSH

Facility

$1,010.00

Service Code	HCPCS 83001
Hospital Charge Code	422830010
Hospital Revenue Code	301
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$979.70
Rate for Payer: AlohaCare Medicaid	$505.00
Rate for Payer: AlohaCare Medicare	$424.20
Rate for Payer: Cash Price	$656.50
Rate for Payer: Cash Price	$656.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$929.20
Rate for Payer: Devoted Health Medicare	$424.20
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.69
Rate for Payer: Hawaii Medical Service Association Commercial	$23.23
Rate for Payer: Hawaii Medical Service Association Medicare	$424.20
Rate for Payer: Hawaii Western Management Group Commercial	$18.58
Rate for Payer: Health Management Network Commercial	$858.50
Rate for Payer: Humana Medicare	$424.20
Rate for Payer: Kaiser Permanente Commercial	$909.00
Rate for Payer: Kaiser Permanente Medicaid	$515.10
Rate for Payer: Kaiser Permanente Medicare	$424.20
Rate for Payer: MDX Hawaii PPO	$979.70
Rate for Payer: Ohana Health Plan Medicaid	$424.20
Rate for Payer: Ohana Health Plan Medicare	$424.20
Rate for Payer: UnitedHealthcare Medicaid	$25.69
Rate for Payer: UnitedHealthcare Medicare	$424.20
Rate for Payer: University Health Alliance Commercial	$48.04

FSH

Facility

$1,010.00

Service Code	HCPCS 83001
Hospital Charge Code	422830010
Hospital Revenue Code	301
Min. Negotiated Rate	$858.50
Max. Negotiated Rate	$979.70
Rate for Payer: Cash Price	$656.50
Rate for Payer: Health Management Network Commercial	$858.50
Rate for Payer: Kaiser Permanente Commercial	$909.00
Rate for Payer: MDX Hawaii PPO	$979.70

FSH DLS

Facility

$1,010.00

Service Code	HCPCS 83001
Hospital Charge Code	422830015
Hospital Revenue Code	301
Min. Negotiated Rate	$858.50
Max. Negotiated Rate	$979.70
Rate for Payer: Cash Price	$656.50
Rate for Payer: Health Management Network Commercial	$858.50
Rate for Payer: Kaiser Permanente Commercial	$909.00
Rate for Payer: MDX Hawaii PPO	$979.70

FSH DLS

Facility

$1,010.00

Service Code	HCPCS 83001
Hospital Charge Code	422830015
Hospital Revenue Code	301
Min. Negotiated Rate	$18.58
Max. Negotiated Rate	$979.70
Rate for Payer: AlohaCare Medicaid	$505.00
Rate for Payer: AlohaCare Medicare	$424.20
Rate for Payer: Cash Price	$656.50
Rate for Payer: Cash Price	$656.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$929.20
Rate for Payer: Devoted Health Medicare	$424.20
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.69
Rate for Payer: Hawaii Medical Service Association Commercial	$23.23
Rate for Payer: Hawaii Medical Service Association Medicare	$424.20
Rate for Payer: Hawaii Western Management Group Commercial	$18.58
Rate for Payer: Health Management Network Commercial	$858.50
Rate for Payer: Humana Medicare	$424.20
Rate for Payer: Kaiser Permanente Commercial	$909.00
Rate for Payer: Kaiser Permanente Medicaid	$515.10
Rate for Payer: Kaiser Permanente Medicare	$424.20
Rate for Payer: MDX Hawaii PPO	$979.70
Rate for Payer: Ohana Health Plan Medicaid	$424.20
Rate for Payer: Ohana Health Plan Medicare	$424.20
Rate for Payer: UnitedHealthcare Medicaid	$25.69
Rate for Payer: UnitedHealthcare Medicare	$424.20
Rate for Payer: University Health Alliance Commercial	$48.04

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$18,985.30

Service Code	MSDRG 793
Min. Negotiated Rate	$18,985.30
Max. Negotiated Rate	$18,985.30
Rate for Payer: Hawaii Medical Service Association Commercial	$18,985.30

Functional Capacity Eval Charge

Facility

$223.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	432977500
Hospital Revenue Code	420
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$93.66
Rate for Payer: Cash Price	$144.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$205.16
Rate for Payer: Devoted Health Medicare	$93.66
Rate for Payer: Hawaii Medical Service Association Medicare	$93.66
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$93.66
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$93.66
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$93.66
Rate for Payer: Ohana Health Plan Medicare	$93.66
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$93.66
Rate for Payer: University Health Alliance Commercial	$162.54

Functional Capacity Eval Charge

Facility

$223.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	432977500
Hospital Revenue Code	420
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$144.95
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

FUNCTIONAL THERAPY GOAL CURRENT

Facility

$1.00

Service Code	HCPCS G8979 GP
Hospital Charge Code	432G89790
Hospital Revenue Code	420
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.65
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

FUNCTIONAL THERAPY GOAL CURRENT

Facility

$1.00

Service Code	HCPCS G8979 GP
Hospital Charge Code	432G89790
Hospital Revenue Code	420
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.42
Rate for Payer: Cash Price	$0.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.92
Rate for Payer: Devoted Health Medicare	$0.42
Rate for Payer: Hawaii Medical Service Association Medicare	$0.42
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.42
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.42
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.42
Rate for Payer: Ohana Health Plan Medicare	$0.42
Rate for Payer: UnitedHealthcare Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

FUNDUS PHOTOGRAPHY W/INTERPRETATION & REPORT

Professional

Both

$324.00

Service Code	HCPCS 92250
Hospital Revenue Code	521
Min. Negotiated Rate	$32.50
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$40.08
Rate for Payer: AlohaCare Medicare	$40.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$40.00
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: Hawaii Western Management Group Commercial	$32.50
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$48.00
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: Ohana Health Plan Medicaid	$40.08
Rate for Payer: Ohana Health Plan Medicare	$40.00
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

Fung. Cul. (Non-Hair/Nail/Skin/Bld) DLS

Facility

$114.00

Service Code	HCPCS 87101
Hospital Charge Code	422871015
Hospital Revenue Code	306
Min. Negotiated Rate	$7.71
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$47.88
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$104.88
Rate for Payer: Devoted Health Medicare	$47.88
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$10.66
Rate for Payer: Hawaii Medical Service Association Commercial	$9.64
Rate for Payer: Hawaii Medical Service Association Medicare	$47.88
Rate for Payer: Hawaii Western Management Group Commercial	$7.71
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$47.88
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$47.88
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$47.88
Rate for Payer: Ohana Health Plan Medicare	$47.88
Rate for Payer: UnitedHealthcare Medicaid	$10.66
Rate for Payer: UnitedHealthcare Medicare	$47.88
Rate for Payer: University Health Alliance Commercial	$19.92

Fung. Cul. (Non-Hair/Nail/Skin/Bld) DLS

Facility

$114.00

Service Code	HCPCS 87101
Hospital Charge Code	422871015
Hospital Revenue Code	306
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

Fungus Culture, Blood/Bone Marrow DLS

Facility

$118.00

Service Code	HCPCS 87102
Hospital Charge Code	422871025
Hospital Revenue Code	306
Min. Negotiated Rate	$100.30
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$76.70
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: MDX Hawaii PPO	$114.46

Fungus Culture, Blood/Bone Marrow DLS

Facility

$118.00

Service Code	HCPCS 87102
Hospital Charge Code	422871025
Hospital Revenue Code	306
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$114.46
Rate for Payer: AlohaCare Medicaid	$59.00
Rate for Payer: AlohaCare Medicare	$49.56
Rate for Payer: Cash Price	$76.70
Rate for Payer: Cash Price	$76.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$108.56
Rate for Payer: Devoted Health Medicare	$49.56
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.61
Rate for Payer: Hawaii Medical Service Association Commercial	$10.51
Rate for Payer: Hawaii Medical Service Association Medicare	$49.56
Rate for Payer: Hawaii Western Management Group Commercial	$8.41
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Humana Medicare	$49.56
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: Kaiser Permanente Medicare	$49.56
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: Ohana Health Plan Medicaid	$49.56
Rate for Payer: Ohana Health Plan Medicare	$49.56
Rate for Payer: UnitedHealthcare Medicaid	$11.61
Rate for Payer: UnitedHealthcare Medicare	$49.56
Rate for Payer: University Health Alliance Commercial	$21.72

furosemide 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904717761
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

furosemide 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904717761
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