Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

I&D RECTUM ABSCESS ED Charge

Facility

$7,251.00

Service Code	HCPCS 45005
Hospital Charge Code	440450050
Hospital Revenue Code	450
Min. Negotiated Rate	$6,163.35
Max. Negotiated Rate	$7,033.47
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Health Management Network Commercial	$6,163.35
Rate for Payer: Kaiser Permanente Commercial	$6,525.90
Rate for Payer: MDX Hawaii PPO	$7,033.47

I&D RECTUM ABSCESS ED Charge

Facility

$7,251.00

Service Code	HCPCS 45005
Hospital Charge Code	440450050
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$7,033.47
Rate for Payer: AlohaCare Medicaid	$3,625.50
Rate for Payer: AlohaCare Medicare	$3,045.42
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Cash Price	$4,713.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6,670.92
Rate for Payer: Devoted Health Medicare	$3,045.42
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	$3,045.42
Rate for Payer: Hawaii Western Management Group Commercial	$6,888.45
Rate for Payer: Health Management Network Commercial	$6,163.35
Rate for Payer: Humana Medicare	$3,045.42
Rate for Payer: Kaiser Permanente Commercial	$6,525.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,045.42
Rate for Payer: MDX Hawaii PPO	$7,033.47
Rate for Payer: Ohana Health Plan Medicaid	$3,045.42
Rate for Payer: Ohana Health Plan Medicare	$3,045.42
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,045.42
Rate for Payer: University Health Alliance Commercial	$5,160.40

I & D SCROTUM CHARGE

Facility

$8,861.00

Service Code	HCPCS 54700
Hospital Charge Code	440547000
Hospital Revenue Code	450
Min. Negotiated Rate	$7,531.85
Max. Negotiated Rate	$8,595.17
Rate for Payer: Cash Price	$5,759.65
Rate for Payer: Health Management Network Commercial	$7,531.85
Rate for Payer: Kaiser Permanente Commercial	$7,974.90
Rate for Payer: MDX Hawaii PPO	$8,595.17

I & D SCROTUM CHARGE

Facility

$8,861.00

Service Code	HCPCS 54700
Hospital Charge Code	440547000
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$8,595.17
Rate for Payer: AlohaCare Medicaid	$4,430.50
Rate for Payer: AlohaCare Medicare	$3,721.62
Rate for Payer: Cash Price	$5,759.65
Rate for Payer: Cash Price	$5,759.65
Rate for Payer: Cash Price	$5,759.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8,152.12
Rate for Payer: Devoted Health Medicare	$3,721.62
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	$3,721.62
Rate for Payer: Hawaii Western Management Group Commercial	$8,417.95
Rate for Payer: Health Management Network Commercial	$7,531.85
Rate for Payer: Humana Medicare	$3,721.62
Rate for Payer: Kaiser Permanente Commercial	$7,974.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,721.62
Rate for Payer: MDX Hawaii PPO	$8,595.17
Rate for Payer: Ohana Health Plan Medicaid	$3,721.62
Rate for Payer: Ohana Health Plan Medicare	$3,721.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,721.62
Rate for Payer: University Health Alliance Commercial	$5,160.40

I&D UPR ARM/ELBO DEEP ABS

Facility

$8,013.00

Service Code	HCPCS 23930
Hospital Charge Code	440239300
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$7,772.61
Rate for Payer: AlohaCare Medicaid	$4,006.50
Rate for Payer: AlohaCare Medicare	$3,365.46
Rate for Payer: Cash Price	$5,208.45
Rate for Payer: Cash Price	$5,208.45
Rate for Payer: Cash Price	$5,208.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7,371.96
Rate for Payer: Devoted Health Medicare	$3,365.46
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	$3,365.46
Rate for Payer: Hawaii Western Management Group Commercial	$7,612.35
Rate for Payer: Health Management Network Commercial	$6,811.05
Rate for Payer: Humana Medicare	$3,365.46
Rate for Payer: Kaiser Permanente Commercial	$7,211.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,365.46
Rate for Payer: MDX Hawaii PPO	$7,772.61
Rate for Payer: Ohana Health Plan Medicaid	$3,365.46
Rate for Payer: Ohana Health Plan Medicare	$3,365.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,365.46
Rate for Payer: University Health Alliance Commercial	$4,035.20

I&D UPR ARM/ELBO DEEP ABS

Facility

$8,013.00

Service Code	HCPCS 23930
Hospital Charge Code	440239300
Hospital Revenue Code	450
Min. Negotiated Rate	$6,811.05
Max. Negotiated Rate	$7,772.61
Rate for Payer: Cash Price	$5,208.45
Rate for Payer: Health Management Network Commercial	$6,811.05
Rate for Payer: Kaiser Permanente Commercial	$7,211.70
Rate for Payer: MDX Hawaii PPO	$7,772.61

IgA (Immunoglobulin A) DLS

Facility

$73.00

Service Code	HCPCS 82784
Hospital Charge Code	422827845
Hospital Revenue Code	301
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$47.45
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

IgA (Immunoglobulin A) DLS

Facility

$73.00

Service Code	HCPCS 82784
Hospital Charge Code	422827845
Hospital Revenue Code	301
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$30.66
Rate for Payer: Cash Price	$47.45
Rate for Payer: Cash Price	$47.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$67.16
Rate for Payer: Devoted Health Medicare	$30.66
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$10.55
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$30.66
Rate for Payer: Hawaii Western Management Group Commercial	$9.30
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$30.66
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$30.66
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$30.66
Rate for Payer: Ohana Health Plan Medicare	$30.66
Rate for Payer: UnitedHealthcare Medicaid	$10.55
Rate for Payer: UnitedHealthcare Medicare	$30.66
Rate for Payer: University Health Alliance Commercial	$19.74

IgE (Immunoglobulin E) DLS

Facility

$113.00

Service Code	HCPCS 82785
Hospital Charge Code	422827855
Hospital Revenue Code	301
Min. Negotiated Rate	$16.46
Max. Negotiated Rate	$109.61
Rate for Payer: AlohaCare Medicaid	$56.50
Rate for Payer: AlohaCare Medicare	$47.46
Rate for Payer: Cash Price	$73.45
Rate for Payer: Cash Price	$73.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$103.96
Rate for Payer: Devoted Health Medicare	$47.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$22.76
Rate for Payer: Hawaii Medical Service Association Commercial	$20.57
Rate for Payer: Hawaii Medical Service Association Medicare	$47.46
Rate for Payer: Hawaii Western Management Group Commercial	$16.46
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Humana Medicare	$47.46
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: Kaiser Permanente Medicaid	$57.63
Rate for Payer: Kaiser Permanente Medicare	$47.46
Rate for Payer: MDX Hawaii PPO	$109.61
Rate for Payer: Ohana Health Plan Medicaid	$47.46
Rate for Payer: Ohana Health Plan Medicare	$47.46
Rate for Payer: UnitedHealthcare Medicaid	$22.76
Rate for Payer: UnitedHealthcare Medicare	$47.46
Rate for Payer: University Health Alliance Commercial	$42.57

IgE (Immunoglobulin E) DLS

Facility

$113.00

Service Code	HCPCS 82785
Hospital Charge Code	422827855
Hospital Revenue Code	301
Min. Negotiated Rate	$96.05
Max. Negotiated Rate	$109.61
Rate for Payer: Cash Price	$73.45
Rate for Payer: Health Management Network Commercial	$96.05
Rate for Payer: Kaiser Permanente Commercial	$101.70
Rate for Payer: MDX Hawaii PPO	$109.61

IgG (Immunoglobulin G) DLS

Facility

$45.00

Service Code	HCPCS 82784
Hospital Charge Code	422827845
Hospital Revenue Code	301
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$18.90
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$41.40
Rate for Payer: Devoted Health Medicare	$18.90
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$10.55
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$18.90
Rate for Payer: Hawaii Western Management Group Commercial	$9.30
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$18.90
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$18.90
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$18.90
Rate for Payer: Ohana Health Plan Medicare	$18.90
Rate for Payer: UnitedHealthcare Medicaid	$10.55
Rate for Payer: UnitedHealthcare Medicare	$18.90
Rate for Payer: University Health Alliance Commercial	$19.74

IgG (Immunoglobulin G) DLS

Facility

$45.00

Service Code	HCPCS 82784
Hospital Charge Code	422827845
Hospital Revenue Code	301
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE

Professional

Both

$0.01

Service Code	HCPCS 90656 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$18.73
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	$18.73
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

IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE

Professional

Both

$71.00

Service Code	HCPCS 90656
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$60.35
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$23.22
Rate for Payer: Cash Price	$46.15
Rate for Payer: Cash Price	$46.15
Rate for Payer: Devoted Health Medicare	$23.22
Rate for Payer: Hawaii Medical Service Association Medicare	$23.22
Rate for Payer: Hawaii Western Management Group Commercial	$18.73
Rate for Payer: Health Management Network Commercial	$60.35
Rate for Payer: Kaiser Permanente Commercial	$27.86
Rate for Payer: Kaiser Permanente Medicaid	$27.86
Rate for Payer: Kaiser Permanente Medicare	$27.86
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$23.22
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$23.22

IIV4 VACC PRESRV FREE 0.5 ML DOS FOR IM USE

Professional

Both

$33.00

Service Code	HCPCS 90686
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$28.05
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$21.45
Rate for Payer: Cash Price	$21.45
Rate for Payer: Hawaii Western Management Group Commercial	$22.01
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

IIV4 VACC PRSRV FREE 0.25 ML DOS FOR IM USE

Professional

Both

$18.00

Service Code	HCPCS 90685
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$23.30
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cash Price	$11.70
Rate for Payer: Hawaii Western Management Group Commercial	$23.30
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

IIV ADJUVANTED VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$263.00

Service Code	HCPCS 90653
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$223.55
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$98.16
Rate for Payer: Cash Price	$170.95
Rate for Payer: Cash Price	$170.95
Rate for Payer: Devoted Health Medicare	$98.16
Rate for Payer: Hawaii Medical Service Association Medicare	$98.16
Rate for Payer: Hawaii Western Management Group Commercial	$61.41
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Kaiser Permanente Commercial	$117.79
Rate for Payer: Kaiser Permanente Medicaid	$117.79
Rate for Payer: Kaiser Permanente Medicare	$117.79
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$98.16
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$98.16

IM ADM INTRANSL/ORAL 1 VACCINE

Professional

Both

$56.00

Service Code	HCPCS 90473
Hospital Revenue Code	771
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$47.60
Rate for Payer: AlohaCare Medicare	$18.78
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$18.78
Rate for Payer: Hawaii Medical Service Association Medicare	$18.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$22.54
Rate for Payer: Kaiser Permanente Medicaid	$22.54
Rate for Payer: Kaiser Permanente Medicare	$22.54
Rate for Payer: Ohana Health Plan Medicare	$18.78
Rate for Payer: UnitedHealthcare Medicare	$18.78

IM ADM INTRANSL/ORAL EA VACCINE

Professional

Both

$38.00

Service Code	HCPCS 90474
Hospital Revenue Code	771
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$32.30
Rate for Payer: AlohaCare Medicare	$13.18
Rate for Payer: Cash Price	$24.70
Rate for Payer: Cash Price	$24.70
Rate for Payer: Devoted Health Medicare	$13.18
Rate for Payer: Hawaii Medical Service Association Medicare	$13.18
Rate for Payer: Hawaii Western Management Group Commercial	$11.00
Rate for Payer: Health Management Network Commercial	$32.30
Rate for Payer: Kaiser Permanente Commercial	$15.82
Rate for Payer: Kaiser Permanente Medicaid	$15.82
Rate for Payer: Kaiser Permanente Medicare	$15.82
Rate for Payer: Ohana Health Plan Medicare	$13.18
Rate for Payer: UnitedHealthcare Medicare	$13.18

IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE

Professional

Both

$15.74

Service Code	HCPCS 90471 SL
Hospital Revenue Code	771
Min. Negotiated Rate	$13.38
Max. Negotiated Rate	$18.00
Rate for Payer: Cash Price	$10.23
Rate for Payer: Cash Price	$10.23
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$13.38

IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE

Professional

Both

$81.00

Service Code	HCPCS 90471
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$68.85
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$52.65
Rate for Payer: Cash Price	$52.65
Rate for Payer: Devoted Health Medicare	$24.10
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE

Professional

Both

$10.00

Service Code	HCPCS 90472 SL
Hospital Revenue Code	771
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$8.50

IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE

Professional

Both

$36.00

Service Code	HCPCS 90472
Hospital Revenue Code	771
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$30.60
Rate for Payer: AlohaCare Medicare	$17.36
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Devoted Health Medicare	$17.36
Rate for Payer: Hawaii Medical Service Association Medicare	$17.36
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$20.83
Rate for Payer: Kaiser Permanente Medicaid	$20.83
Rate for Payer: Kaiser Permanente Medicare	$20.83
Rate for Payer: Ohana Health Plan Medicare	$17.36
Rate for Payer: UnitedHealthcare Medicare	$17.36

IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX

Professional

Both

$57.00

Service Code	HCPCS 90460
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$48.45
Rate for Payer: AlohaCare Medicare	$25.16
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cash Price	$37.05
Rate for Payer: Devoted Health Medicare	$25.16
Rate for Payer: Hawaii Medical Service Association Medicare	$25.16
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Kaiser Permanente Commercial	$30.19
Rate for Payer: Kaiser Permanente Medicaid	$30.19
Rate for Payer: Kaiser Permanente Medicare	$30.19
Rate for Payer: Ohana Health Plan Medicare	$25.16
Rate for Payer: UnitedHealthcare Medicare	$25.16

IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT

Professional

Both

$32.00

Service Code	HCPCS 90461
Hospital Revenue Code	771
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$27.20
Rate for Payer: AlohaCare Medicare	$8.86
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Devoted Health Medicare	$8.86
Rate for Payer: Hawaii Medical Service Association Medicare	$8.86
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$10.63
Rate for Payer: Kaiser Permanente Medicaid	$10.63
Rate for Payer: Kaiser Permanente Medicare	$10.63
Rate for Payer: Ohana Health Plan Medicare	$8.86
Rate for Payer: UnitedHealthcare Medicare	$8.86

Know your out-of-pocket cost for care.

All Charges