Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

OPTIC FORAMINA

Facility

$340.00

Service Code	HCPCS 70190
Hospital Charge Code	424701900
Hospital Revenue Code	320
Min. Negotiated Rate	$289.00
Max. Negotiated Rate	$329.80
Rate for Payer: Cash Price	$221.00
Rate for Payer: Health Management Network Commercial	$289.00
Rate for Payer: Kaiser Permanente Commercial	$306.00
Rate for Payer: MDX Hawaii PPO	$329.80

ORAL AIRWAY 50MM

Facility

$4.00

Hospital Charge Code	8469
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

ORAL AIRWAY 50MM

Facility

$4.00

Hospital Charge Code	8469
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

ORAL AIRWAY 60MM

Facility

$3.00

Hospital Charge Code	8470
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

ORAL AIRWAY 60MM

Facility

$3.00

Hospital Charge Code	8470
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

ORAL AIRWAY 70MM

Facility

$9.00

Hospital Charge Code	8471
Hospital Revenue Code	270
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 Medicare	$3.78
Rate for Payer: University Health Alliance Commercial	$6.56

ORAL AIRWAY 70MM

Facility

$9.00

Hospital Charge Code	8471
Hospital Revenue Code	270
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

ORAL AIRWAY 80mm

Facility

$34.00

Hospital Charge Code	8017
Hospital Revenue Code	272
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

ORAL AIRWAY 80mm

Facility

$34.00

Hospital Charge Code	8017
Hospital Revenue Code	272
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

ORAL AIRWAY 90mm

Facility

$34.00

Hospital Charge Code	8018
Hospital Revenue Code	272
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

ORAL AIRWAY 90mm

Facility

$34.00

Hospital Charge Code	8018
Hospital Revenue Code	272
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

ORBITAL PROCEDURES WITH CC/MCC

Facility

$19,103.81

Service Code	MSDRG 113
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$19,103.81

Service Code	MSDRG 114
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$19,103.81
Rate for Payer: Hawaii Medical Service Association Commercial	$19,103.81
Rate for Payer: University Health Alliance Commercial	$10,400.00

ORBITS COMP MIN 4 VWS

Facility

$369.00

Service Code	HCPCS 70200
Hospital Charge Code	424702000
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

ORBITS COMP MIN 4 VWS

Facility

$369.00

Service Code	HCPCS 70200
Hospital Charge Code	424702000
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.96
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$90.41

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$25,669.27

Service Code	MSDRG 884
Min. Negotiated Rate	$25,669.27
Max. Negotiated Rate	$25,669.27
Rate for Payer: Hawaii Medical Service Association Commercial	$25,669.27

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$51,717.76

Service Code	MSDRG 620
Min. Negotiated Rate	$51,717.76
Max. Negotiated Rate	$51,717.76
Rate for Payer: Hawaii Medical Service Association Commercial	$51,717.76

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$51,717.76

Service Code	MSDRG 619
Min. Negotiated Rate	$51,717.76
Max. Negotiated Rate	$51,717.76
Rate for Payer: Hawaii Medical Service Association Commercial	$51,717.76

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$51,504.45

Service Code	MSDRG 621
Min. Negotiated Rate	$51,504.45
Max. Negotiated Rate	$51,504.45
Rate for Payer: Hawaii Medical Service Association Commercial	$51,504.45

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$38,586.86

Service Code	MSDRG 940
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$38,586.86

Service Code	MSDRG 939
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$38,586.86

Service Code	MSDRG 941
Min. Negotiated Rate	$38,586.86
Max. Negotiated Rate	$38,586.86
Rate for Payer: Hawaii Medical Service Association Commercial	$38,586.86

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$85,990.86

Service Code	MSDRG 876
Min. Negotiated Rate	$85,990.86
Max. Negotiated Rate	$85,990.86
Rate for Payer: Hawaii Medical Service Association Commercial	$85,990.86

OR SCISSORS STRAIGHT SH/SH 5.5"

Facility

$3.00

Hospital Charge Code	8547
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

OR SCISSORS STRAIGHT SH/SH 5.5"

Facility

$3.00

Hospital Charge Code	8547
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

Know your out-of-pocket cost for care.

All Charges