Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC

Facility

$16,378.08

Service Code	MSDRG 379
Min. Negotiated Rate	$16,378.08
Max. Negotiated Rate	$16,378.08
Rate for Payer: Hawaii Medical Service Association Commercial	$16,378.08

GASTROINTESTINAL OBSTRUCTION WITH CC

Facility

$16,662.51

Service Code	MSDRG 389
Min. Negotiated Rate	$16,662.51
Max. Negotiated Rate	$16,662.51
Rate for Payer: Hawaii Medical Service Association Commercial	$16,662.51

GASTROINTESTINAL OBSTRUCTION WITH MCC

Facility

$18,771.98

Service Code	MSDRG 388
Min. Negotiated Rate	$18,771.98
Max. Negotiated Rate	$18,771.98
Rate for Payer: Hawaii Medical Service Association Commercial	$18,771.98

GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC

Facility

$13,273.12

Service Code	MSDRG 390
Min. Negotiated Rate	$13,273.12
Max. Negotiated Rate	$13,273.12
Rate for Payer: Hawaii Medical Service Association Commercial	$13,273.12

GASTRO INTUB W/ASP ED Charge

Facility

$667.00

Service Code	HCPCS 43753
Hospital Charge Code	317437530
Hospital Revenue Code	361
Min. Negotiated Rate	$566.95
Max. Negotiated Rate	$646.99
Rate for Payer: Cash Price	$433.55
Rate for Payer: Health Management Network Commercial	$566.95
Rate for Payer: Kaiser Permanente Commercial	$600.30
Rate for Payer: MDX Hawaii PPO	$646.99

GASTRO INTUB W/ASP ED Charge

Facility

$667.00

Service Code	HCPCS 43753
Hospital Charge Code	317437530
Hospital Revenue Code	361
Min. Negotiated Rate	$12.77
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$333.50
Rate for Payer: AlohaCare Medicare	$280.14
Rate for Payer: Cash Price	$433.55
Rate for Payer: Cash Price	$433.55
Rate for Payer: Cash Price	$433.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$613.64
Rate for Payer: Devoted Health Medicare	$280.14
Rate for Payer: Hawaii Medical Service Association Commercial	$318.85
Rate for Payer: Hawaii Medical Service Association Medicare	$280.14
Rate for Payer: Health Management Network Commercial	$566.95
Rate for Payer: Humana Medicare	$280.14
Rate for Payer: Kaiser Permanente Commercial	$600.30
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$280.14
Rate for Payer: MDX Hawaii PPO	$646.99
Rate for Payer: Ohana Health Plan Medicaid	$280.14
Rate for Payer: Ohana Health Plan Medicare	$280.14
Rate for Payer: UnitedHealthcare Medicaid	$12.77
Rate for Payer: UnitedHealthcare Medicare	$280.14
Rate for Payer: University Health Alliance Commercial	$486.18

GAUZE 4X4 STERILE 10'S

Facility

$34.00

Hospital Charge Code	8457
Hospital Revenue Code	270
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

GAUZE 4X4 STERILE 10'S

Facility

$34.00

Hospital Charge Code	8457
Hospital Revenue Code	270
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$14.28
Rate for Payer: Cash Price	$22.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.28
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association Medicare	$14.28
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$14.28
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$14.28
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$14.28
Rate for Payer: Ohana Health Plan Medicare	$14.28
Rate for Payer: UnitedHealthcare Medicare	$14.28
Rate for Payer: University Health Alliance Commercial	$24.78

GAUZE 4x4 STERILE 5'S

Facility

$1,952.00

Hospital Charge Code	8458
Hospital Revenue Code	270
Min. Negotiated Rate	$819.84
Max. Negotiated Rate	$1,893.44
Rate for Payer: AlohaCare Medicaid	$976.00
Rate for Payer: AlohaCare Medicare	$819.84
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,795.84
Rate for Payer: Devoted Health Medicare	$819.84
Rate for Payer: Hawaii Medical Service Association Medicare	$819.84
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.40
Rate for Payer: Health Management Network Commercial	$1,659.20
Rate for Payer: Humana Medicare	$819.84
Rate for Payer: Kaiser Permanente Commercial	$1,756.80
Rate for Payer: Kaiser Permanente Medicaid	$995.52
Rate for Payer: Kaiser Permanente Medicare	$819.84
Rate for Payer: MDX Hawaii PPO	$1,893.44
Rate for Payer: Ohana Health Plan Medicaid	$819.84
Rate for Payer: Ohana Health Plan Medicare	$819.84
Rate for Payer: UnitedHealthcare Medicare	$819.84
Rate for Payer: University Health Alliance Commercial	$1,422.81

GAUZE 4x4 STERILE 5'S

Facility

$1,952.00

Hospital Charge Code	8458
Hospital Revenue Code	270
Min. Negotiated Rate	$1,659.20
Max. Negotiated Rate	$1,893.44
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Health Management Network Commercial	$1,659.20
Rate for Payer: Kaiser Permanente Commercial	$1,756.80
Rate for Payer: MDX Hawaii PPO	$1,893.44

GAUZE KERLIX 4"

Facility

$54.00

Hospital Charge Code	8126
Hospital Revenue Code	270
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$22.68
Rate for Payer: Cash Price	$35.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$49.68
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association Medicare	$22.68
Rate for Payer: Hawaii Western Management Group Commercial	$51.30
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$22.68
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$22.68
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$22.68
Rate for Payer: Ohana Health Plan Medicare	$22.68
Rate for Payer: UnitedHealthcare Medicare	$22.68
Rate for Payer: University Health Alliance Commercial	$39.36

GAUZE KERLIX 4"

Facility

$54.00

Hospital Charge Code	8126
Hospital Revenue Code	270
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

GBS Screen, DNA Amplification DLS

Facility

$345.00

Service Code	HCPCS 87653
Hospital Charge Code	422876535
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$334.65
Rate for Payer: AlohaCare Medicaid	$172.50
Rate for Payer: AlohaCare Medicare	$144.90
Rate for Payer: Cash Price	$224.25
Rate for Payer: Cash Price	$224.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$317.40
Rate for Payer: Devoted Health Medicare	$144.90
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$49.04
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$144.90
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$293.25
Rate for Payer: Humana Medicare	$144.90
Rate for Payer: Kaiser Permanente Commercial	$310.50
Rate for Payer: Kaiser Permanente Medicaid	$175.95
Rate for Payer: Kaiser Permanente Medicare	$144.90
Rate for Payer: MDX Hawaii PPO	$334.65
Rate for Payer: Ohana Health Plan Medicaid	$144.90
Rate for Payer: Ohana Health Plan Medicare	$144.90
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$144.90
Rate for Payer: University Health Alliance Commercial	$90.72

GBS Screen, DNA Amplification DLS

Facility

$345.00

Service Code	HCPCS 87653
Hospital Charge Code	422876535
Hospital Revenue Code	306
Min. Negotiated Rate	$293.25
Max. Negotiated Rate	$334.65
Rate for Payer: Cash Price	$224.25
Rate for Payer: Health Management Network Commercial	$293.25
Rate for Payer: Kaiser Permanente Commercial	$310.50
Rate for Payer: MDX Hawaii PPO	$334.65

GC, PCR DLS

Facility

$101.00

Service Code	HCPCS 87591
Hospital Charge Code	422875915
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$42.42
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.92
Rate for Payer: Devoted Health Medicare	$42.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$42.42
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$42.42
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$42.42
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$42.42
Rate for Payer: Ohana Health Plan Medicare	$42.42
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$42.42
Rate for Payer: University Health Alliance Commercial	$90.72

GC, PCR DLS

Facility

$101.00

Service Code	HCPCS 87591
Hospital Charge Code	422875915
Hospital Revenue Code	306
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

GELFOAM 12-7MM

Facility

$13.00

Hospital Charge Code	8424
Hospital Revenue Code	270
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$8.45
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

GELFOAM 12-7MM

Facility

$13.00

Hospital Charge Code	8424
Hospital Revenue Code	270
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$5.46
Rate for Payer: Cash Price	$8.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.96
Rate for Payer: Devoted Health Medicare	$5.46
Rate for Payer: Hawaii Medical Service Association Medicare	$5.46
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$5.46
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$5.46
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$5.46
Rate for Payer: Ohana Health Plan Medicare	$5.46
Rate for Payer: UnitedHealthcare Medicare	$5.46
Rate for Payer: University Health Alliance Commercial	$9.48

gemfibrozil 600 mg Tab [KMC]

Facility

$9.00

Service Code	NDC 16714010102
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

gemfibrozil 600 mg Tab [KMC]

Facility

$9.00

Service Code	NDC 16714010102
Hospital Revenue Code	250
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$3.78
Rate for Payer: Cash Price	$5.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.28
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Hawaii Medical Service Association Medicare	$3.78
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$3.78
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$3.78
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$3.78
Rate for Payer: Ohana Health Plan Medicare	$3.78
Rate for Payer: UnitedHealthcare Medicaid	$5.40
Rate for Payer: UnitedHealthcare Medicare	$3.78
Rate for Payer: University Health Alliance Commercial	$6.56

General Health Panel 4

Facility

$259.00

Service Code	HCPCS 80050
Hospital Charge Code	422800505
Hospital Revenue Code	301
Min. Negotiated Rate	$41.19
Max. Negotiated Rate	$251.23
Rate for Payer: AlohaCare Medicaid	$129.50
Rate for Payer: AlohaCare Medicare	$108.78
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$238.28
Rate for Payer: Devoted Health Medicare	$108.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$41.19
Rate for Payer: Hawaii Medical Service Association Medicare	$108.78
Rate for Payer: Hawaii Western Management Group Commercial	$246.05
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Humana Medicare	$108.78
Rate for Payer: Kaiser Permanente Commercial	$233.10
Rate for Payer: Kaiser Permanente Medicaid	$132.09
Rate for Payer: Kaiser Permanente Medicare	$108.78
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: Ohana Health Plan Medicaid	$108.78
Rate for Payer: Ohana Health Plan Medicare	$108.78
Rate for Payer: UnitedHealthcare Medicaid	$41.19
Rate for Payer: UnitedHealthcare Medicare	$108.78
Rate for Payer: University Health Alliance Commercial	$92.74

General Health Panel 4

Facility

$259.00

Service Code	HCPCS 80050
Hospital Charge Code	422800505
Hospital Revenue Code	301
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$168.35
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$233.10
Rate for Payer: MDX Hawaii PPO	$251.23

General Health Panel 4 DLS

Facility

$259.00

Service Code	HCPCS 80050
Hospital Charge Code	422800505
Hospital Revenue Code	301
Min. Negotiated Rate	$220.15
Max. Negotiated Rate	$251.23
Rate for Payer: Cash Price	$168.35
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$233.10
Rate for Payer: MDX Hawaii PPO	$251.23

General Health Panel 4 DLS

Facility

$259.00

Service Code	HCPCS 80050
Hospital Charge Code	422800505
Hospital Revenue Code	301
Min. Negotiated Rate	$41.19
Max. Negotiated Rate	$251.23
Rate for Payer: AlohaCare Medicaid	$129.50
Rate for Payer: AlohaCare Medicare	$108.78
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$238.28
Rate for Payer: Devoted Health Medicare	$108.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$41.19
Rate for Payer: Hawaii Medical Service Association Medicare	$108.78
Rate for Payer: Hawaii Western Management Group Commercial	$246.05
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Humana Medicare	$108.78
Rate for Payer: Kaiser Permanente Commercial	$233.10
Rate for Payer: Kaiser Permanente Medicaid	$132.09
Rate for Payer: Kaiser Permanente Medicare	$108.78
Rate for Payer: MDX Hawaii PPO	$251.23
Rate for Payer: Ohana Health Plan Medicaid	$108.78
Rate for Payer: Ohana Health Plan Medicare	$108.78
Rate for Payer: UnitedHealthcare Medicaid	$41.19
Rate for Payer: UnitedHealthcare Medicare	$108.78
Rate for Payer: University Health Alliance Commercial	$92.74

Genital Culture DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

Know your out-of-pocket cost for care.

All Charges