Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$139,699.59

Service Code	MSDRG 836
Min. Negotiated Rate	$139,699.59
Max. Negotiated Rate	$139,699.59
Rate for Payer: Hawaii Medical Service Association Commercial	$139,699.59

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$9,125.27

Service Code	MSDRG 121
Min. Negotiated Rate	$9,125.27
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$9,125.27

Service Code	MSDRG 122
Min. Negotiated Rate	$9,125.27
Max. Negotiated Rate	$9,125.27
Rate for Payer: Hawaii Medical Service Association Commercial	$9,125.27

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$28,940.14

Service Code	MSDRG 281
Min. Negotiated Rate	$28,940.14
Max. Negotiated Rate	$28,940.14
Rate for Payer: Hawaii Medical Service Association Commercial	$28,940.14

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$33,467.22

Service Code	MSDRG 280
Min. Negotiated Rate	$33,467.22
Max. Negotiated Rate	$33,467.22
Rate for Payer: Hawaii Medical Service Association Commercial	$33,467.22

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$25,337.44

Service Code	MSDRG 282
Min. Negotiated Rate	$25,337.44
Max. Negotiated Rate	$25,337.44
Rate for Payer: Hawaii Medical Service Association Commercial	$25,337.44

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$55,913.02

Service Code	MSDRG 284
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$55,913.02

Service Code	MSDRG 283
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$55,913.02

Service Code	MSDRG 285
Min. Negotiated Rate	$55,913.02
Max. Negotiated Rate	$55,913.02
Rate for Payer: Hawaii Medical Service Association Commercial	$55,913.02

acyclovir 200 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 72578000201
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

acyclovir 200 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 72578000201
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

acyclovir 500 mg / 10 mL IV Soln [KMC]

Facility

$9.02

Service Code	HCPCS J0133
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$8.75
Rate for Payer: AlohaCare Medicaid	$4.51
Rate for Payer: AlohaCare Medicare	$3.79
Rate for Payer: Cash Price	$5.86
Rate for Payer: Cash Price	$5.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.30
Rate for Payer: Devoted Health Medicare	$3.79
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$3.79
Rate for Payer: Hawaii Western Management Group Commercial	$8.57
Rate for Payer: Health Management Network Commercial	$7.67
Rate for Payer: Humana Medicare	$3.79
Rate for Payer: Kaiser Permanente Commercial	$8.12
Rate for Payer: Kaiser Permanente Medicaid	$4.60
Rate for Payer: Kaiser Permanente Medicare	$3.79
Rate for Payer: MDX Hawaii PPO	$8.75
Rate for Payer: Ohana Health Plan Medicaid	$3.79
Rate for Payer: Ohana Health Plan Medicare	$3.79
Rate for Payer: UnitedHealthcare Medicaid	$5.41
Rate for Payer: UnitedHealthcare Medicare	$3.79
Rate for Payer: University Health Alliance Commercial	$6.57

acyclovir 500 mg / 10 mL IV Soln [KMC]

Facility

$9.02

Service Code	HCPCS J0133
Hospital Revenue Code	636
Min. Negotiated Rate	$7.67
Max. Negotiated Rate	$8.75
Rate for Payer: Cash Price	$5.86
Rate for Payer: Health Management Network Commercial	$7.67
Rate for Payer: Kaiser Permanente Commercial	$8.12
Rate for Payer: MDX Hawaii PPO	$8.75

acyclovir 800 mg Tab [KMC]

Facility

$16.86

Service Code	NDC 31722077801
Hospital Revenue Code	250
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$16.35
Rate for Payer: AlohaCare Medicaid	$8.43
Rate for Payer: AlohaCare Medicare	$7.08
Rate for Payer: Cash Price	$10.96
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.51
Rate for Payer: Devoted Health Medicare	$7.08
Rate for Payer: Hawaii Medical Service Association Medicare	$7.08
Rate for Payer: Hawaii Western Management Group Commercial	$16.02
Rate for Payer: Health Management Network Commercial	$14.33
Rate for Payer: Humana Medicare	$7.08
Rate for Payer: Kaiser Permanente Commercial	$15.17
Rate for Payer: Kaiser Permanente Medicaid	$8.60
Rate for Payer: Kaiser Permanente Medicare	$7.08
Rate for Payer: MDX Hawaii PPO	$16.35
Rate for Payer: Ohana Health Plan Medicaid	$7.08
Rate for Payer: Ohana Health Plan Medicare	$7.08
Rate for Payer: UnitedHealthcare Medicaid	$10.12
Rate for Payer: UnitedHealthcare Medicare	$7.08
Rate for Payer: University Health Alliance Commercial	$12.29

acyclovir 800 mg Tab [KMC]

Facility

$16.86

Service Code	NDC 31722077801
Hospital Revenue Code	250
Min. Negotiated Rate	$14.33
Max. Negotiated Rate	$16.35
Rate for Payer: Cash Price	$10.96
Rate for Payer: Health Management Network Commercial	$14.33
Rate for Payer: Kaiser Permanente Commercial	$15.17
Rate for Payer: MDX Hawaii PPO	$16.35

acyclovir topical 5% Oint [KMC]

Facility

$106.35

Service Code	NDC 00378870006
Hospital Revenue Code	250
Min. Negotiated Rate	$44.67
Max. Negotiated Rate	$103.16
Rate for Payer: AlohaCare Medicaid	$53.17
Rate for Payer: AlohaCare Medicare	$44.67
Rate for Payer: Cash Price	$69.13
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$97.84
Rate for Payer: Devoted Health Medicare	$44.67
Rate for Payer: Hawaii Medical Service Association Medicare	$44.67
Rate for Payer: Hawaii Western Management Group Commercial	$101.03
Rate for Payer: Health Management Network Commercial	$90.40
Rate for Payer: Humana Medicare	$44.67
Rate for Payer: Kaiser Permanente Commercial	$95.72
Rate for Payer: Kaiser Permanente Medicaid	$54.24
Rate for Payer: Kaiser Permanente Medicare	$44.67
Rate for Payer: MDX Hawaii PPO	$103.16
Rate for Payer: Ohana Health Plan Medicaid	$44.67
Rate for Payer: Ohana Health Plan Medicare	$44.67
Rate for Payer: UnitedHealthcare Medicaid	$63.81
Rate for Payer: UnitedHealthcare Medicare	$44.67
Rate for Payer: University Health Alliance Commercial	$77.52

acyclovir topical 5% Oint [KMC]

Facility

$106.35

Service Code	NDC 00378870006
Hospital Revenue Code	250
Min. Negotiated Rate	$90.40
Max. Negotiated Rate	$103.16
Rate for Payer: Cash Price	$69.13
Rate for Payer: Health Management Network Commercial	$90.40
Rate for Payer: Kaiser Permanente Commercial	$95.72
Rate for Payer: MDX Hawaii PPO	$103.16

ADAPTIC 3X3"

Facility

$2.00

Hospital Charge Code	8008
Hospital Revenue Code	272
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

ADAPTIC 3X3"

Facility

$2.00

Hospital Charge Code	8008
Hospital Revenue Code	272
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

ADAPTIC 3X8"

Facility

$2.00

Hospital Charge Code	8009
Hospital Revenue Code	272
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

ADAPTIC 3X8"

Facility

$2.00

Hospital Charge Code	8009
Hospital Revenue Code	272
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

Additional Resp Allergen Profile DLS

Facility

$144.00

Service Code	HCPCS 86003
Hospital Charge Code	422860037
Hospital Revenue Code	300
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: MDX Hawaii PPO	$139.68

Additional Resp Allergen Profile DLS

Facility

$144.00

Service Code	HCPCS 86003
Hospital Charge Code	422860037
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicare	$60.48
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$132.48
Rate for Payer: Devoted Health Medicare	$60.48
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	$60.48
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$60.48
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$60.48
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$60.48
Rate for Payer: Ohana Health Plan Medicare	$60.48
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$60.48
Rate for Payer: University Health Alliance Commercial	$13.51

adenosine 6mg/2mL IV Sol [KMC]

Facility

$15.00

Service Code	HCPCS J0153
Hospital Revenue Code	636
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.75
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

adenosine 6mg/2mL IV Sol [KMC]

Facility

$15.00

Service Code	HCPCS J0153
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$6.30
Rate for Payer: Cash Price	$9.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.80
Rate for Payer: Devoted Health Medicare	$6.30
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.46
Rate for Payer: Hawaii Medical Service Association Medicare	$6.30
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$6.30
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$6.30
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$6.30
Rate for Payer: Ohana Health Plan Medicare	$6.30
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: UnitedHealthcare Medicare	$6.30
Rate for Payer: University Health Alliance Commercial	$10.93

Know your out-of-pocket cost for care.

All Charges