Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Allergen 1 DLS

Facility

$56.00

Service Code	HCPCS 86003
Hospital Charge Code	422860035
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$23.52
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$51.52
Rate for Payer: Devoted Health Medicare	$23.52
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	$23.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$23.52
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$23.52
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$23.52
Rate for Payer: Ohana Health Plan Medicare	$23.52
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$23.52
Rate for Payer: University Health Alliance Commercial	$13.51

ALLERGIC REACTIONS WITH MCC

Facility

$13,130.91

Service Code	MSDRG 915
Min. Negotiated Rate	$13,130.91
Max. Negotiated Rate	$13,130.91
Rate for Payer: Hawaii Medical Service Association Commercial	$13,130.91

ALLERGIC REACTIONS WITHOUT MCC

Facility

$13,130.91

Service Code	MSDRG 916
Min. Negotiated Rate	$13,130.91
Max. Negotiated Rate	$13,130.91
Rate for Payer: Hawaii Medical Service Association Commercial	$13,130.91

ALLEVYN ADHESIVE 5X5

Facility

$19.00

Hospital Charge Code	8408
Hospital Revenue Code	270
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$12.35
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

ALLEVYN ADHESIVE 5X5

Facility

$19.00

Hospital Charge Code	8408
Hospital Revenue Code	270
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$7.98
Rate for Payer: Cash Price	$12.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$17.48
Rate for Payer: Devoted Health Medicare	$7.98
Rate for Payer: Hawaii Medical Service Association Medicare	$7.98
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$7.98
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$7.98
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$7.98
Rate for Payer: Ohana Health Plan Medicare	$7.98
Rate for Payer: UnitedHealthcare Medicare	$7.98
Rate for Payer: University Health Alliance Commercial	$13.85

ALLEVYN ADHISIVE 7X7

Facility

$24.00

Hospital Charge Code	8418
Hospital Revenue Code	270
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$10.08
Rate for Payer: Cash Price	$15.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.08
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$10.08
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$10.08
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$10.08
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$10.08
Rate for Payer: Ohana Health Plan Medicare	$10.08
Rate for Payer: UnitedHealthcare Medicare	$10.08
Rate for Payer: University Health Alliance Commercial	$17.49

ALLEVYN ADHISIVE 7X7

Facility

$24.00

Hospital Charge Code	8418
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

ALLEVYN GENTLE BORDER LITE 4X4

Facility

$42.00

Hospital Charge Code	8409
Hospital Revenue Code	270
Min. Negotiated Rate	$17.64
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$21.00
Rate for Payer: AlohaCare Medicare	$17.64
Rate for Payer: Cash Price	$27.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$38.64
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$17.64
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$17.64
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$17.64
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$17.64
Rate for Payer: Ohana Health Plan Medicare	$17.64
Rate for Payer: UnitedHealthcare Medicare	$17.64
Rate for Payer: University Health Alliance Commercial	$30.61

ALLEVYN GENTLE BORDER LITE 4X4

Facility

$42.00

Hospital Charge Code	8409
Hospital Revenue Code	270
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$27.30
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: MDX Hawaii PPO	$40.74

ALLEVYN GENTLE BORDER LITE 6X6

Facility

$125.00

Hospital Charge Code	8411
Hospital Revenue Code	270
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$62.50
Rate for Payer: AlohaCare Medicare	$52.50
Rate for Payer: Cash Price	$81.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$115.00
Rate for Payer: Devoted Health Medicare	$52.50
Rate for Payer: Hawaii Medical Service Association Medicare	$52.50
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Humana Medicare	$52.50
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$52.50
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: Ohana Health Plan Medicaid	$52.50
Rate for Payer: Ohana Health Plan Medicare	$52.50
Rate for Payer: UnitedHealthcare Medicare	$52.50
Rate for Payer: University Health Alliance Commercial	$91.11

ALLEVYN GENTLE BORDER LITE 6X6

Facility

$125.00

Hospital Charge Code	8411
Hospital Revenue Code	270
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: MDX Hawaii PPO	$121.25

ALLEVYN LIFE

Facility

$4.00

Hospital Charge Code	8533
Hospital Revenue Code	270
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

ALLEVYN LIFE

Facility

$4.00

Hospital Charge Code	8533
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

ALLEVYN NON-ADHESIVE 4" X 4"

Facility

$40.00

Hospital Charge Code	8531
Hospital Revenue Code	270
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$26.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: MDX Hawaii PPO	$38.80

ALLEVYN NON-ADHESIVE 4" X 4"

Facility

$40.00

Hospital Charge Code	8531
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$16.80
Rate for Payer: Cash Price	$26.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$36.80
Rate for Payer: Devoted Health Medicare	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$16.80
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$16.80
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$16.80
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$16.80
Rate for Payer: Ohana Health Plan Medicare	$16.80
Rate for Payer: UnitedHealthcare Medicare	$16.80
Rate for Payer: University Health Alliance Commercial	$29.16

ALLEVYN THIN 4X4

Facility

$83.00

Hospital Charge Code	8417
Hospital Revenue Code	270
Min. Negotiated Rate	$34.86
Max. Negotiated Rate	$80.51
Rate for Payer: AlohaCare Medicaid	$41.50
Rate for Payer: AlohaCare Medicare	$34.86
Rate for Payer: Cash Price	$53.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$76.36
Rate for Payer: Devoted Health Medicare	$34.86
Rate for Payer: Hawaii Medical Service Association Medicare	$34.86
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Humana Medicare	$34.86
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: Kaiser Permanente Medicare	$34.86
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: Ohana Health Plan Medicaid	$34.86
Rate for Payer: Ohana Health Plan Medicare	$34.86
Rate for Payer: UnitedHealthcare Medicare	$34.86
Rate for Payer: University Health Alliance Commercial	$60.50

ALLEVYN THIN 4X4

Facility

$83.00

Hospital Charge Code	8417
Hospital Revenue Code	270
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$53.95
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: MDX Hawaii PPO	$80.51

ALLIGATOR FORCEPS 3-1/2"

Facility

$5.00

Hospital Charge Code	8541
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

ALLIGATOR FORCEPS 3-1/2"

Facility

$5.00

Hospital Charge Code	8541
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

ALLIGATOR FORCEPS 5-1/2"

Facility

$3.00

Hospital Charge Code	8542
Hospital Revenue Code	270
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

ALLIGATOR FORCEPS 5-1/2"

Facility

$3.00

Hospital Charge Code	8542
Hospital Revenue Code	270
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

ALLOGENEIC BONE MARROW TRANSPLANT

Facility

$228,961.32

Service Code	MSDRG 014
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$228,961.32
Rate for Payer: Hawaii Medical Service Association Commercial	$228,961.32
Rate for Payer: University Health Alliance Commercial	$10,400.00

allopurinol 100 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904704161
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

allopurinol 100 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904704161
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

allopurinol 300 mg Tab [KMC]

Facility

$3.69

Service Code	NDC 16714057701
Hospital Revenue Code	250
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$3.58
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.14
Rate for Payer: Kaiser Permanente Commercial	$3.32
Rate for Payer: MDX Hawaii PPO	$3.58

Know your out-of-pocket cost for care.

All Charges