Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

OT Moderate Complex Units

Facility

$389.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	426971660
Hospital Revenue Code	434
Min. Negotiated Rate	$330.65
Max. Negotiated Rate	$377.33
Rate for Payer: Cash Price	$252.85
Rate for Payer: Health Management Network Commercial	$330.65
Rate for Payer: Kaiser Permanente Commercial	$350.10
Rate for Payer: MDX Hawaii PPO	$377.33

OT Muscle Test Extremity EX Hands

Facility

$173.00

Service Code	HCPCS 95831 GO
Hospital Charge Code	432958310
Hospital Revenue Code	430
Min. Negotiated Rate	$72.66
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: Deseret Mutual Benefit Administrators Commercial	$159.16
Rate for Payer: Devoted Health Medicare	$72.66
Rate for Payer: Hawaii Medical Service Association Medicare	$72.66
Rate for Payer: Hawaii Western Management Group Commercial	$164.35
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 Medicare	$72.66
Rate for Payer: University Health Alliance Commercial	$126.10

OT Muscle Test Extremity EX Hands

Facility

$173.00

Service Code	HCPCS 95831 GO
Hospital Charge Code	432958310
Hospital Revenue Code	430
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

OT Physical Performance Test Charges

Facility

$223.00

Service Code	HCPCS 97750 GO
Hospital Charge Code	426977500
Hospital Revenue Code	430
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$93.66
Rate for Payer: Cash Price	$144.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$205.16
Rate for Payer: Devoted Health Medicare	$93.66
Rate for Payer: Hawaii Medical Service Association Medicare	$93.66
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$93.66
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$93.66
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$93.66
Rate for Payer: Ohana Health Plan Medicare	$93.66
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$93.66
Rate for Payer: University Health Alliance Commercial	$162.54

OT Physical Performance Test Charges

Facility

$223.00

Service Code	HCPCS 97750 GO
Hospital Charge Code	426977500
Hospital Revenue Code	430
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$144.95
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

OT RE-EVALUATION Occupational

Facility

$396.00

Service Code	HCPCS 97004 GO
Hospital Charge Code	432970040
Hospital Revenue Code	434
Min. Negotiated Rate	$166.32
Max. Negotiated Rate	$384.12
Rate for Payer: AlohaCare Medicaid	$198.00
Rate for Payer: AlohaCare Medicare	$166.32
Rate for Payer: Cash Price	$257.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$364.32
Rate for Payer: Devoted Health Medicare	$166.32
Rate for Payer: Hawaii Medical Service Association Medicare	$166.32
Rate for Payer: Hawaii Western Management Group Commercial	$376.20
Rate for Payer: Health Management Network Commercial	$336.60
Rate for Payer: Humana Medicare	$166.32
Rate for Payer: Kaiser Permanente Commercial	$356.40
Rate for Payer: Kaiser Permanente Medicaid	$201.96
Rate for Payer: Kaiser Permanente Medicare	$166.32
Rate for Payer: MDX Hawaii PPO	$384.12
Rate for Payer: Ohana Health Plan Medicaid	$166.32
Rate for Payer: Ohana Health Plan Medicare	$166.32
Rate for Payer: UnitedHealthcare Medicare	$166.32
Rate for Payer: University Health Alliance Commercial	$288.64

OT RE-EVALUATION Occupational

Facility

$396.00

Service Code	HCPCS 97004 GO
Hospital Charge Code	432970040
Hospital Revenue Code	434
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$384.12
Rate for Payer: Cash Price	$257.40
Rate for Payer: Health Management Network Commercial	$336.60
Rate for Payer: Kaiser Permanente Commercial	$356.40
Rate for Payer: MDX Hawaii PPO	$384.12

OT ReEval Units

Facility

$270.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	426971680
Hospital Revenue Code	434
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$261.90
Rate for Payer: Cash Price	$175.50
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: Kaiser Permanente Commercial	$243.00
Rate for Payer: MDX Hawaii PPO	$261.90

OT ReEval Units

Facility

$270.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	426971680
Hospital Revenue Code	434
Min. Negotiated Rate	$74.97
Max. Negotiated Rate	$261.90
Rate for Payer: AlohaCare Medicaid	$135.00
Rate for Payer: AlohaCare Medicare	$113.40
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cash Price	$175.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$248.40
Rate for Payer: Devoted Health Medicare	$113.40
Rate for Payer: Hawaii Medical Service Association Medicare	$113.40
Rate for Payer: Hawaii Western Management Group Commercial	$256.50
Rate for Payer: Health Management Network Commercial	$229.50
Rate for Payer: Humana Medicare	$113.40
Rate for Payer: Kaiser Permanente Commercial	$243.00
Rate for Payer: Kaiser Permanente Medicaid	$137.70
Rate for Payer: Kaiser Permanente Medicare	$113.40
Rate for Payer: MDX Hawaii PPO	$261.90
Rate for Payer: Ohana Health Plan Medicaid	$113.40
Rate for Payer: Ohana Health Plan Medicare	$113.40
Rate for Payer: UnitedHealthcare Medicaid	$74.97
Rate for Payer: UnitedHealthcare Medicare	$113.40
Rate for Payer: University Health Alliance Commercial	$196.80

Ova And Parasite, Concentrate/Smear DLS

Facility

$170.00

Service Code	HCPCS 87177
Hospital Charge Code	422872095
Hospital Revenue Code	306
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$164.90
Rate for Payer: AlohaCare Medicaid	$85.00
Rate for Payer: AlohaCare Medicare	$71.40
Rate for Payer: Cash Price	$110.50
Rate for Payer: Cash Price	$110.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$156.40
Rate for Payer: Devoted Health Medicare	$71.40
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$12.30
Rate for Payer: Hawaii Medical Service Association Commercial	$11.12
Rate for Payer: Hawaii Medical Service Association Medicare	$71.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.90
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Humana Medicare	$71.40
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: Kaiser Permanente Medicare	$71.40
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: Ohana Health Plan Medicaid	$71.40
Rate for Payer: Ohana Health Plan Medicare	$71.40
Rate for Payer: UnitedHealthcare Medicaid	$12.30
Rate for Payer: UnitedHealthcare Medicare	$71.40
Rate for Payer: University Health Alliance Commercial	$23.00

Ova And Parasite, Concentrate/Smear DLS

Facility

$170.00

Service Code	HCPCS 87177
Hospital Charge Code	422872095
Hospital Revenue Code	306
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$110.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$153.00
Rate for Payer: MDX Hawaii PPO	$164.90

oxacillin 2 gm vial [KMC]

Facility

$112.50

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$95.62
Max. Negotiated Rate	$109.12
Rate for Payer: Cash Price	$73.12
Rate for Payer: Health Management Network Commercial	$95.62
Rate for Payer: Kaiser Permanente Commercial	$101.25
Rate for Payer: MDX Hawaii PPO	$109.12

oxacillin 2 gm vial [KMC]

Facility

$112.50

Service Code	HCPCS J2700
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$109.12
Rate for Payer: AlohaCare Medicaid	$56.25
Rate for Payer: AlohaCare Medicare	$47.25
Rate for Payer: Cash Price	$73.12
Rate for Payer: Cash Price	$73.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$103.50
Rate for Payer: Devoted Health Medicare	$47.25
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.82
Rate for Payer: Hawaii Medical Service Association Medicare	$47.25
Rate for Payer: Hawaii Western Management Group Commercial	$106.88
Rate for Payer: Health Management Network Commercial	$95.62
Rate for Payer: Humana Medicare	$47.25
Rate for Payer: Kaiser Permanente Commercial	$101.25
Rate for Payer: Kaiser Permanente Medicaid	$57.38
Rate for Payer: Kaiser Permanente Medicare	$47.25
Rate for Payer: MDX Hawaii PPO	$109.12
Rate for Payer: Ohana Health Plan Medicaid	$47.25
Rate for Payer: Ohana Health Plan Medicare	$47.25
Rate for Payer: UnitedHealthcare Medicaid	$67.50
Rate for Payer: UnitedHealthcare Medicare	$47.25
Rate for Payer: University Health Alliance Commercial	$82.00

OXcarbazepine 300 mg Tab [KMC]

Facility

$11.02

Service Code	NDC 60687072201
Hospital Revenue Code	250
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$10.69
Rate for Payer: Cash Price	$7.16
Rate for Payer: Health Management Network Commercial	$9.37
Rate for Payer: Kaiser Permanente Commercial	$9.92
Rate for Payer: MDX Hawaii PPO	$10.69

OXcarbazepine 300 mg Tab [KMC]

Facility

$11.02

Service Code	NDC 60687072201
Hospital Revenue Code	250
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$10.69
Rate for Payer: AlohaCare Medicaid	$5.51
Rate for Payer: AlohaCare Medicare	$4.63
Rate for Payer: Cash Price	$7.16
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.14
Rate for Payer: Devoted Health Medicare	$4.63
Rate for Payer: Hawaii Medical Service Association Medicare	$4.63
Rate for Payer: Hawaii Western Management Group Commercial	$10.47
Rate for Payer: Health Management Network Commercial	$9.37
Rate for Payer: Humana Medicare	$4.63
Rate for Payer: Kaiser Permanente Commercial	$9.92
Rate for Payer: Kaiser Permanente Medicaid	$5.62
Rate for Payer: Kaiser Permanente Medicare	$4.63
Rate for Payer: MDX Hawaii PPO	$10.69
Rate for Payer: Ohana Health Plan Medicaid	$4.63
Rate for Payer: Ohana Health Plan Medicare	$4.63
Rate for Payer: UnitedHealthcare Medicaid	$6.61
Rate for Payer: UnitedHealthcare Medicare	$4.63
Rate for Payer: University Health Alliance Commercial	$8.03

oxybutynin 15 mg/24 hr ER tab

Facility

$12.63

Service Code	NDC 62175027237
Hospital Revenue Code	250
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$12.25
Rate for Payer: Cash Price	$8.21
Rate for Payer: Health Management Network Commercial	$10.74
Rate for Payer: Kaiser Permanente Commercial	$11.37
Rate for Payer: MDX Hawaii PPO	$12.25

oxybutynin 15 mg/24 hr ER tab

Facility

$12.63

Service Code	NDC 62175027237
Hospital Revenue Code	250
Min. Negotiated Rate	$5.30
Max. Negotiated Rate	$12.25
Rate for Payer: AlohaCare Medicaid	$6.32
Rate for Payer: AlohaCare Medicare	$5.30
Rate for Payer: Cash Price	$8.21
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.62
Rate for Payer: Devoted Health Medicare	$5.30
Rate for Payer: Hawaii Medical Service Association Medicare	$5.30
Rate for Payer: Hawaii Western Management Group Commercial	$12.00
Rate for Payer: Health Management Network Commercial	$10.74
Rate for Payer: Humana Medicare	$5.30
Rate for Payer: Kaiser Permanente Commercial	$11.37
Rate for Payer: Kaiser Permanente Medicaid	$6.44
Rate for Payer: Kaiser Permanente Medicare	$5.30
Rate for Payer: MDX Hawaii PPO	$12.25
Rate for Payer: Ohana Health Plan Medicaid	$5.30
Rate for Payer: Ohana Health Plan Medicare	$5.30
Rate for Payer: UnitedHealthcare Medicaid	$7.58
Rate for Payer: UnitedHealthcare Medicare	$5.30
Rate for Payer: University Health Alliance Commercial	$9.21

oxybutynin 5 mg/24 hours ER tab [KMC]

Facility

$13.15

Service Code	NDC 68382025501
Hospital Revenue Code	250
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$12.76
Rate for Payer: Cash Price	$8.55
Rate for Payer: Health Management Network Commercial	$11.18
Rate for Payer: Kaiser Permanente Commercial	$11.84
Rate for Payer: MDX Hawaii PPO	$12.76

oxybutynin 5 mg/24 hours ER tab [KMC]

Facility

$13.15

Service Code	NDC 68382025501
Hospital Revenue Code	250
Min. Negotiated Rate	$5.52
Max. Negotiated Rate	$12.76
Rate for Payer: AlohaCare Medicaid	$6.58
Rate for Payer: AlohaCare Medicare	$5.52
Rate for Payer: Cash Price	$8.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.10
Rate for Payer: Devoted Health Medicare	$5.52
Rate for Payer: Hawaii Medical Service Association Medicare	$5.52
Rate for Payer: Hawaii Western Management Group Commercial	$12.49
Rate for Payer: Health Management Network Commercial	$11.18
Rate for Payer: Humana Medicare	$5.52
Rate for Payer: Kaiser Permanente Commercial	$11.84
Rate for Payer: Kaiser Permanente Medicaid	$6.71
Rate for Payer: Kaiser Permanente Medicare	$5.52
Rate for Payer: MDX Hawaii PPO	$12.76
Rate for Payer: Ohana Health Plan Medicaid	$5.52
Rate for Payer: Ohana Health Plan Medicare	$5.52
Rate for Payer: UnitedHealthcare Medicaid	$7.89
Rate for Payer: UnitedHealthcare Medicare	$5.52
Rate for Payer: University Health Alliance Commercial	$9.59

oxybutynin 5 mg Tab [KMC]

Facility

$3.04

Service Code	NDC 70954000510
Hospital Revenue Code	250
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$2.95
Rate for Payer: Cash Price	$1.98
Rate for Payer: Health Management Network Commercial	$2.58
Rate for Payer: Kaiser Permanente Commercial	$2.74
Rate for Payer: MDX Hawaii PPO	$2.95

oxybutynin 5 mg Tab [KMC]

Facility

$3.04

Service Code	NDC 70954000510
Hospital Revenue Code	250
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$2.95
Rate for Payer: AlohaCare Medicaid	$1.52
Rate for Payer: AlohaCare Medicare	$1.28
Rate for Payer: Cash Price	$1.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.80
Rate for Payer: Devoted Health Medicare	$1.28
Rate for Payer: Hawaii Medical Service Association Medicare	$1.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.89
Rate for Payer: Health Management Network Commercial	$2.58
Rate for Payer: Humana Medicare	$1.28
Rate for Payer: Kaiser Permanente Commercial	$2.74
Rate for Payer: Kaiser Permanente Medicaid	$1.55
Rate for Payer: Kaiser Permanente Medicare	$1.28
Rate for Payer: MDX Hawaii PPO	$2.95
Rate for Payer: Ohana Health Plan Medicaid	$1.28
Rate for Payer: Ohana Health Plan Medicare	$1.28
Rate for Payer: UnitedHealthcare Medicaid	$1.82
Rate for Payer: UnitedHealthcare Medicare	$1.28
Rate for Payer: University Health Alliance Commercial	$2.22

oxyCODONE 10 mg Tab [KMC]

Facility

$3.43

Service Code	NDC 68084096801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.33
Rate for Payer: Cash Price	$2.23
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Kaiser Permanente Commercial	$3.09
Rate for Payer: MDX Hawaii PPO	$3.33

oxyCODONE 10 mg Tab [KMC]

Facility

$3.43

Service Code	NDC 68084096801
Hospital Revenue Code	250
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$3.33
Rate for Payer: AlohaCare Medicaid	$1.72
Rate for Payer: AlohaCare Medicare	$1.44
Rate for Payer: Cash Price	$2.23
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.16
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Hawaii Medical Service Association Medicare	$1.44
Rate for Payer: Hawaii Western Management Group Commercial	$3.26
Rate for Payer: Health Management Network Commercial	$2.92
Rate for Payer: Humana Medicare	$1.44
Rate for Payer: Kaiser Permanente Commercial	$3.09
Rate for Payer: Kaiser Permanente Medicaid	$1.75
Rate for Payer: Kaiser Permanente Medicare	$1.44
Rate for Payer: MDX Hawaii PPO	$3.33
Rate for Payer: Ohana Health Plan Medicaid	$1.44
Rate for Payer: Ohana Health Plan Medicare	$1.44
Rate for Payer: UnitedHealthcare Medicaid	$2.06
Rate for Payer: UnitedHealthcare Medicare	$1.44
Rate for Payer: University Health Alliance Commercial	$2.50

oxyCODONE 15 mg ER Tab [KMC]

Facility

$40.03

Service Code	NDC 59011041510
Hospital Revenue Code	250
Min. Negotiated Rate	$16.81
Max. Negotiated Rate	$38.83
Rate for Payer: AlohaCare Medicaid	$20.02
Rate for Payer: AlohaCare Medicare	$16.81
Rate for Payer: Cash Price	$26.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$36.83
Rate for Payer: Devoted Health Medicare	$16.81
Rate for Payer: Hawaii Medical Service Association Medicare	$16.81
Rate for Payer: Hawaii Western Management Group Commercial	$38.03
Rate for Payer: Health Management Network Commercial	$34.03
Rate for Payer: Humana Medicare	$16.81
Rate for Payer: Kaiser Permanente Commercial	$36.03
Rate for Payer: Kaiser Permanente Medicaid	$20.42
Rate for Payer: Kaiser Permanente Medicare	$16.81
Rate for Payer: MDX Hawaii PPO	$38.83
Rate for Payer: Ohana Health Plan Medicaid	$16.81
Rate for Payer: Ohana Health Plan Medicare	$16.81
Rate for Payer: UnitedHealthcare Medicaid	$24.02
Rate for Payer: UnitedHealthcare Medicare	$16.81
Rate for Payer: University Health Alliance Commercial	$29.18

oxyCODONE 15 mg ER Tab [KMC]

Facility

$40.03

Service Code	NDC 59011041510
Hospital Revenue Code	250
Min. Negotiated Rate	$34.03
Max. Negotiated Rate	$38.83
Rate for Payer: Cash Price	$26.02
Rate for Payer: Health Management Network Commercial	$34.03
Rate for Payer: Kaiser Permanente Commercial	$36.03
Rate for Payer: MDX Hawaii PPO	$38.83

Know your out-of-pocket cost for care.

All Charges