Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC

Facility

$65,464.92

Service Code	MSDRG 420
Min. Negotiated Rate	$65,464.92
Max. Negotiated Rate	$65,464.92
Rate for Payer: Hawaii Medical Service Association Commercial	$65,464.92

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC

Facility

$58,093.60

Service Code	MSDRG 422
Min. Negotiated Rate	$58,093.60
Max. Negotiated Rate	$58,093.60
Rate for Payer: Hawaii Medical Service Association Commercial	$58,093.60

HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE

Professional

Both

$83.00

Service Code	HCPCS 90633
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$70.55
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$53.95
Rate for Payer: Cash Price	$53.95
Rate for Payer: Hawaii Western Management Group Commercial	$36.02
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE

Professional

Both

$0.01

Service Code	HCPCS 90633 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.02
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$36.02
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

HEPB VACCINE ADULT 3 DOSE SCHEDULE FOR IM USE

Professional

Both

$219.00

Service Code	HCPCS 90746
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$186.15
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$75.15
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Devoted Health Medicare	$75.15
Rate for Payer: Hawaii Medical Service Association Medicare	$75.15
Rate for Payer: Hawaii Western Management Group Commercial	$65.64
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: Kaiser Permanente Commercial	$90.18
Rate for Payer: Kaiser Permanente Medicaid	$90.18
Rate for Payer: Kaiser Permanente Medicare	$90.18
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$75.15
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$75.15

HEPB VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM

Professional

Both

$0.01

Service Code	HCPCS 90744 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$26.77
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$26.77
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

HEPB VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM

Professional

Both

$91.00

Service Code	HCPCS 90744
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$77.35
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$33.20
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$33.20
Rate for Payer: Hawaii Medical Service Association Medicare	$33.20
Rate for Payer: Hawaii Western Management Group Commercial	$26.77
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$39.84
Rate for Payer: Kaiser Permanente Medicaid	$39.84
Rate for Payer: Kaiser Permanente Medicare	$39.84
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$33.20
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$33.20

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC

Facility

$31,950.30

Service Code	MSDRG 354
Min. Negotiated Rate	$31,950.30
Max. Negotiated Rate	$31,950.30
Rate for Payer: Hawaii Medical Service Association Commercial	$31,950.30

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC

Facility

$41,407.39

Service Code	MSDRG 353
Min. Negotiated Rate	$41,407.39
Max. Negotiated Rate	$41,407.39
Rate for Payer: Hawaii Medical Service Association Commercial	$41,407.39

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC

Facility

$23,607.19

Service Code	MSDRG 355
Min. Negotiated Rate	$23,607.19
Max. Negotiated Rate	$23,607.19
Rate for Payer: Hawaii Medical Service Association Commercial	$23,607.19

Herpes Simplex Cult w/Reflex to ID DLS

Facility

$277.00

Service Code	HCPCS 87255
Hospital Charge Code	422872555
Hospital Revenue Code	306
Min. Negotiated Rate	$33.86
Max. Negotiated Rate	$268.69
Rate for Payer: AlohaCare Medicaid	$138.50
Rate for Payer: AlohaCare Medicare	$116.34
Rate for Payer: Cash Price	$180.05
Rate for Payer: Cash Price	$180.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$254.84
Rate for Payer: Devoted Health Medicare	$116.34
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$42.92
Rate for Payer: Hawaii Medical Service Association Commercial	$42.33
Rate for Payer: Hawaii Medical Service Association Medicare	$116.34
Rate for Payer: Hawaii Western Management Group Commercial	$33.86
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Humana Medicare	$116.34
Rate for Payer: Kaiser Permanente Commercial	$249.30
Rate for Payer: Kaiser Permanente Medicaid	$141.27
Rate for Payer: Kaiser Permanente Medicare	$116.34
Rate for Payer: MDX Hawaii PPO	$268.69
Rate for Payer: Ohana Health Plan Medicaid	$116.34
Rate for Payer: Ohana Health Plan Medicare	$116.34
Rate for Payer: UnitedHealthcare Medicaid	$42.92
Rate for Payer: UnitedHealthcare Medicare	$116.34
Rate for Payer: University Health Alliance Commercial	$79.40

Herpes Simplex Cult w/Reflex to ID DLS

Facility

$277.00

Service Code	HCPCS 87255
Hospital Charge Code	422872555
Hospital Revenue Code	306
Min. Negotiated Rate	$235.45
Max. Negotiated Rate	$268.69
Rate for Payer: Cash Price	$180.05
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Kaiser Permanente Commercial	$249.30
Rate for Payer: MDX Hawaii PPO	$268.69

Herpes Simplex Type 1 & 2 Ab, IgG DLS

Facility

$175.00

Service Code	HCPCS 86696
Hospital Charge Code	422866951
Hospital Revenue Code	301
Min. Negotiated Rate	$148.75
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$113.75
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75

Herpes Simplex Type 1 & 2 Ab, IgG DLS

Facility

$175.00

Service Code	HCPCS 86696
Hospital Charge Code	422866951
Hospital Revenue Code	301
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$113.75
Rate for Payer: Cash Price	$113.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$161.00
Rate for Payer: Devoted Health Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$27.05
Rate for Payer: Hawaii Medical Service Association Commercial	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Western Management Group Commercial	$19.35
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$27.05
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$50.04

HFO CF T-SPICA ULN/RAD Occupational

Facility

$446.00

Service Code	HCPCS L3913
Hospital Charge Code	432L39130
Hospital Revenue Code	274
Min. Negotiated Rate	$249.76
Max. Negotiated Rate	$432.62
Rate for Payer: Cash Price	$289.90
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: University Health Alliance Commercial	$249.76

HFO CF T-SPICA ULN/RAD Occupational

Facility

$446.00

Service Code	HCPCS L3913
Hospital Charge Code	432L39130
Hospital Revenue Code	274
Min. Negotiated Rate	$116.21
Max. Negotiated Rate	$432.62
Rate for Payer: AlohaCare Medicaid	$223.00
Rate for Payer: AlohaCare Medicare	$187.32
Rate for Payer: Cash Price	$289.90
Rate for Payer: Cash Price	$289.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$410.32
Rate for Payer: Devoted Health Medicare	$187.32
Rate for Payer: Hawaii Medical Service Association Medicare	$187.32
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Humana Medicare	$187.32
Rate for Payer: Kaiser Permanente Commercial	$401.40
Rate for Payer: Kaiser Permanente Medicaid	$227.46
Rate for Payer: Kaiser Permanente Medicare	$187.32
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: Ohana Health Plan Medicaid	$187.32
Rate for Payer: Ohana Health Plan Medicare	$187.32
Rate for Payer: UnitedHealthcare Medicaid	$116.21
Rate for Payer: UnitedHealthcare Medicare	$187.32
Rate for Payer: University Health Alliance Commercial	$249.76

HFO PF CARROT CONTRACT Occupational

Facility

$207.00

Service Code	HCPCS L3929
Hospital Charge Code	432L39290
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

HFO PF CARROT CONTRACT Occupational

Facility

$207.00

Service Code	HCPCS L3929
Hospital Charge Code	432L39290
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: 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	$91.24
Rate for Payer: UnitedHealthcare Medicare	$86.94
Rate for Payer: University Health Alliance Commercial	$115.92

HFO PF PALM GRIP T-SPICA Occupational

Facility

$207.00

Service Code	HCPCS L3923
Hospital Charge Code	432L39230
Hospital Revenue Code	274
Min. Negotiated Rate	$16.69
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	$16.69
Rate for Payer: UnitedHealthcare Medicare	$86.94
Rate for Payer: University Health Alliance Commercial	$115.92

HFO PF PALM GRIP T-SPICA Occupational

Facility

$207.00

Service Code	HCPCS L3923
Hospital Charge Code	432L39230
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

HIB-HEPB VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$89.00

Service Code	HCPCS 90748
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$75.65
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Hawaii Western Management Group Commercial	$47.04
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE

Professional

Both

$89.00

Service Code	HCPCS 90648
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$75.65
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Hawaii Western Management Group Commercial	$29.55
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE

Professional

Both

$0.01

Service Code	HCPCS 90648 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$29.55
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$29.55
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC

Facility

$48,517.99

Service Code	MSDRG 481
Min. Negotiated Rate	$48,517.99
Max. Negotiated Rate	$48,517.99
Rate for Payer: Hawaii Medical Service Association Commercial	$48,517.99

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC

Facility

$49,750.50

Service Code	MSDRG 480
Min. Negotiated Rate	$49,750.50
Max. Negotiated Rate	$49,750.50
Rate for Payer: Hawaii Medical Service Association Commercial	$49,750.50

Know your out-of-pocket cost for care.

All Charges