Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

ampicillin 2 g Inj [KMC]

Facility

$64.80

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$62.86
Rate for Payer: AlohaCare Medicaid	$32.40
Rate for Payer: AlohaCare Medicare	$27.22
Rate for Payer: Cash Price	$42.12
Rate for Payer: Cash Price	$42.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$59.62
Rate for Payer: Devoted Health Medicare	$27.22
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.49
Rate for Payer: Hawaii Medical Service Association Medicare	$27.22
Rate for Payer: Hawaii Western Management Group Commercial	$61.56
Rate for Payer: Health Management Network Commercial	$55.08
Rate for Payer: Humana Medicare	$27.22
Rate for Payer: Kaiser Permanente Commercial	$58.32
Rate for Payer: Kaiser Permanente Medicaid	$33.05
Rate for Payer: Kaiser Permanente Medicare	$27.22
Rate for Payer: MDX Hawaii PPO	$62.86
Rate for Payer: Ohana Health Plan Medicaid	$27.22
Rate for Payer: Ohana Health Plan Medicare	$27.22
Rate for Payer: UnitedHealthcare Medicaid	$38.88
Rate for Payer: UnitedHealthcare Medicare	$27.22
Rate for Payer: University Health Alliance Commercial	$47.23

ampicillin 2 g Inj [KMC]

Facility

$64.80

Service Code	HCPCS J0290
Hospital Revenue Code	636
Min. Negotiated Rate	$55.08
Max. Negotiated Rate	$62.86
Rate for Payer: Cash Price	$42.12
Rate for Payer: Health Management Network Commercial	$55.08
Rate for Payer: Kaiser Permanente Commercial	$58.32
Rate for Payer: MDX Hawaii PPO	$62.86

ampicillin-sulbactam 1.5 gm (1+0.5) vial [KMC]

Facility

$37.02

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$35.91
Rate for Payer: AlohaCare Medicaid	$18.51
Rate for Payer: AlohaCare Medicare	$15.55
Rate for Payer: Cash Price	$24.06
Rate for Payer: Cash Price	$24.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.06
Rate for Payer: Devoted Health Medicare	$15.55
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.49
Rate for Payer: Hawaii Medical Service Association Medicare	$15.55
Rate for Payer: Hawaii Western Management Group Commercial	$35.17
Rate for Payer: Health Management Network Commercial	$31.47
Rate for Payer: Humana Medicare	$15.55
Rate for Payer: Kaiser Permanente Commercial	$33.32
Rate for Payer: Kaiser Permanente Medicaid	$18.88
Rate for Payer: Kaiser Permanente Medicare	$15.55
Rate for Payer: MDX Hawaii PPO	$35.91
Rate for Payer: Ohana Health Plan Medicaid	$15.55
Rate for Payer: Ohana Health Plan Medicare	$15.55
Rate for Payer: UnitedHealthcare Medicaid	$22.21
Rate for Payer: UnitedHealthcare Medicare	$15.55
Rate for Payer: University Health Alliance Commercial	$26.98

ampicillin-sulbactam 1.5 gm (1+0.5) vial [KMC]

Facility

$37.02

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$31.47
Max. Negotiated Rate	$35.91
Rate for Payer: Cash Price	$24.06
Rate for Payer: Health Management Network Commercial	$31.47
Rate for Payer: Kaiser Permanente Commercial	$33.32
Rate for Payer: MDX Hawaii PPO	$35.91

ampicillin-sulbactam 2gm-1gm (=3gm) REC Inj [KMC]

Facility

$18.43

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$15.67
Max. Negotiated Rate	$17.88
Rate for Payer: Cash Price	$11.98
Rate for Payer: Health Management Network Commercial	$15.67
Rate for Payer: Kaiser Permanente Commercial	$16.59
Rate for Payer: MDX Hawaii PPO	$17.88

ampicillin-sulbactam 2gm-1gm (=3gm) REC Inj [KMC]

Facility

$18.43

Service Code	HCPCS J0295
Hospital Revenue Code	636
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$17.88
Rate for Payer: AlohaCare Medicaid	$9.21
Rate for Payer: AlohaCare Medicare	$7.74
Rate for Payer: Cash Price	$11.98
Rate for Payer: Cash Price	$11.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.96
Rate for Payer: Devoted Health Medicare	$7.74
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.49
Rate for Payer: Hawaii Medical Service Association Medicare	$7.74
Rate for Payer: Hawaii Western Management Group Commercial	$17.51
Rate for Payer: Health Management Network Commercial	$15.67
Rate for Payer: Humana Medicare	$7.74
Rate for Payer: Kaiser Permanente Commercial	$16.59
Rate for Payer: Kaiser Permanente Medicaid	$9.40
Rate for Payer: Kaiser Permanente Medicare	$7.74
Rate for Payer: MDX Hawaii PPO	$17.88
Rate for Payer: Ohana Health Plan Medicaid	$7.74
Rate for Payer: Ohana Health Plan Medicare	$7.74
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$7.74
Rate for Payer: University Health Alliance Commercial	$13.43

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$80,800.12

Service Code	MSDRG 240
Min. Negotiated Rate	$80,800.12
Max. Negotiated Rate	$80,800.12
Rate for Payer: Hawaii Medical Service Association Commercial	$80,800.12

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$80,800.12

Service Code	MSDRG 239
Min. Negotiated Rate	$80,800.12
Max. Negotiated Rate	$80,800.12
Rate for Payer: Hawaii Medical Service Association Commercial	$80,800.12

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$80,800.12

Service Code	MSDRG 241
Min. Negotiated Rate	$80,800.12
Max. Negotiated Rate	$80,800.12
Rate for Payer: Hawaii Medical Service Association Commercial	$80,800.12

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$40,696.33

Service Code	MSDRG 475
Min. Negotiated Rate	$40,696.33
Max. Negotiated Rate	$40,696.33
Rate for Payer: Hawaii Medical Service Association Commercial	$40,696.33

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$40,696.33

Service Code	MSDRG 474
Min. Negotiated Rate	$40,696.33
Max. Negotiated Rate	$40,696.33
Rate for Payer: Hawaii Medical Service Association Commercial	$40,696.33

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$40,696.33

Service Code	MSDRG 476
Min. Negotiated Rate	$40,696.33
Max. Negotiated Rate	$40,696.33
Rate for Payer: Hawaii Medical Service Association Commercial	$40,696.33

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$71,603.74

Service Code	MSDRG 617
Min. Negotiated Rate	$71,603.74
Max. Negotiated Rate	$71,603.74
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$71,603.74

Service Code	MSDRG 616
Min. Negotiated Rate	$71,603.74
Max. Negotiated Rate	$71,603.74
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$71,603.74

Service Code	MSDRG 618
Min. Negotiated Rate	$71,603.74
Max. Negotiated Rate	$71,603.74
Rate for Payer: Hawaii Medical Service Association Commercial	$71,603.74

Amylase DLS

Facility

$110.00

Service Code	HCPCS 82150
Hospital Charge Code	422821505
Hospital Revenue Code	301
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$106.70
Rate for Payer: AlohaCare Medicaid	$55.00
Rate for Payer: AlohaCare Medicare	$46.20
Rate for Payer: Cash Price	$71.50
Rate for Payer: Cash Price	$71.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$101.20
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.96
Rate for Payer: Hawaii Medical Service Association Commercial	$8.10
Rate for Payer: Hawaii Medical Service Association Medicare	$46.20
Rate for Payer: Hawaii Western Management Group Commercial	$6.48
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Humana Medicare	$46.20
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: Kaiser Permanente Medicare	$46.20
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: Ohana Health Plan Medicaid	$46.20
Rate for Payer: Ohana Health Plan Medicare	$46.20
Rate for Payer: UnitedHealthcare Medicaid	$8.96
Rate for Payer: UnitedHealthcare Medicare	$46.20
Rate for Payer: University Health Alliance Commercial	$16.76

Amylase DLS

Facility

$110.00

Service Code	HCPCS 82150
Hospital Charge Code	422821505
Hospital Revenue Code	301
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$71.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: MDX Hawaii PPO	$106.70

Amylase Level

Facility

$110.00

Service Code	HCPCS 82150
Hospital Charge Code	422821500
Hospital Revenue Code	301
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$71.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: MDX Hawaii PPO	$106.70

Amylase Level

Facility

$110.00

Service Code	HCPCS 82150
Hospital Charge Code	422821500
Hospital Revenue Code	301
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$106.70
Rate for Payer: AlohaCare Medicaid	$55.00
Rate for Payer: AlohaCare Medicare	$46.20
Rate for Payer: Cash Price	$71.50
Rate for Payer: Cash Price	$71.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$101.20
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.96
Rate for Payer: Hawaii Medical Service Association Commercial	$8.10
Rate for Payer: Hawaii Medical Service Association Medicare	$46.20
Rate for Payer: Hawaii Western Management Group Commercial	$6.48
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Humana Medicare	$46.20
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: Kaiser Permanente Medicare	$46.20
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: Ohana Health Plan Medicaid	$46.20
Rate for Payer: Ohana Health Plan Medicare	$46.20
Rate for Payer: UnitedHealthcare Medicaid	$8.96
Rate for Payer: UnitedHealthcare Medicare	$46.20
Rate for Payer: University Health Alliance Commercial	$16.76

Anaerobic Culture DLS

Facility

$173.00

Service Code	HCPCS 87075
Hospital Charge Code	422870755
Hospital Revenue Code	306
Min. Negotiated Rate	$147.05
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$112.45
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$167.81

Anaerobic Culture DLS

Facility

$173.00

Service Code	HCPCS 87075
Hospital Charge Code	422870755
Hospital Revenue Code	306
Min. Negotiated Rate	$9.47
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicare	$72.66
Rate for Payer: Cash Price	$112.45
Rate for Payer: Cash Price	$112.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$159.16
Rate for Payer: Devoted Health Medicare	$72.66
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$13.08
Rate for Payer: Hawaii Medical Service Association Commercial	$11.84
Rate for Payer: Hawaii Medical Service Association Medicare	$72.66
Rate for Payer: Hawaii Western Management Group Commercial	$9.47
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$72.66
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$72.66
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$72.66
Rate for Payer: Ohana Health Plan Medicare	$72.66
Rate for Payer: UnitedHealthcare Medicaid	$13.08
Rate for Payer: UnitedHealthcare Medicare	$72.66
Rate for Payer: University Health Alliance Commercial	$24.46

ANAL AND STOMAL PROCEDURES WITH CC

Facility

$22,872.43

Service Code	MSDRG 348
Min. Negotiated Rate	$22,872.43
Max. Negotiated Rate	$22,872.43
Rate for Payer: Hawaii Medical Service Association Commercial	$22,872.43

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$28,513.51

Service Code	MSDRG 347
Min. Negotiated Rate	$28,513.51
Max. Negotiated Rate	$28,513.51
Rate for Payer: Hawaii Medical Service Association Commercial	$28,513.51

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$14,197.50

Service Code	MSDRG 349
Min. Negotiated Rate	$14,197.50
Max. Negotiated Rate	$14,197.50
Rate for Payer: Hawaii Medical Service Association Commercial	$14,197.50

anastrozole 1 mg Tab[KMC]

Facility

$53.38

Service Code	NDC 51991062090
Hospital Revenue Code	250
Min. Negotiated Rate	$45.37
Max. Negotiated Rate	$51.78
Rate for Payer: Cash Price	$34.70
Rate for Payer: Health Management Network Commercial	$45.37
Rate for Payer: Kaiser Permanente Commercial	$48.04
Rate for Payer: MDX Hawaii PPO	$51.78

Know your out-of-pocket cost for care.

All Charges