Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$32,874.67

Service Code	MSDRG 544
Min. Negotiated Rate	$32,874.67
Max. Negotiated Rate	$32,874.67
Rate for Payer: Hawaii Medical Service Association Commercial	$32,874.67

patiromer 25.2 g REC packet [KMC]

Facility

$143.68

Service Code	NDC 53436025230
Hospital Revenue Code	250
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$139.37
Rate for Payer: AlohaCare Medicaid	$71.84
Rate for Payer: AlohaCare Medicare	$60.35
Rate for Payer: Cash Price	$93.39
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$132.19
Rate for Payer: Devoted Health Medicare	$60.35
Rate for Payer: Hawaii Medical Service Association Medicare	$60.35
Rate for Payer: Hawaii Western Management Group Commercial	$136.50
Rate for Payer: Health Management Network Commercial	$122.13
Rate for Payer: Humana Medicare	$60.35
Rate for Payer: Kaiser Permanente Commercial	$129.31
Rate for Payer: Kaiser Permanente Medicaid	$73.28
Rate for Payer: Kaiser Permanente Medicare	$60.35
Rate for Payer: MDX Hawaii PPO	$139.37
Rate for Payer: Ohana Health Plan Medicaid	$60.35
Rate for Payer: Ohana Health Plan Medicare	$60.35
Rate for Payer: UnitedHealthcare Medicaid	$86.21
Rate for Payer: UnitedHealthcare Medicare	$60.35
Rate for Payer: University Health Alliance Commercial	$104.73

patiromer 25.2 g REC packet [KMC]

Facility

$143.68

Service Code	NDC 53436025230
Hospital Revenue Code	250
Min. Negotiated Rate	$122.13
Max. Negotiated Rate	$139.37
Rate for Payer: Cash Price	$93.39
Rate for Payer: Health Management Network Commercial	$122.13
Rate for Payer: Kaiser Permanente Commercial	$129.31
Rate for Payer: MDX Hawaii PPO	$139.37

patiromer 8.4 gm packets [KMC]

Facility

$131.33

Service Code	NDC 53436008430
Hospital Revenue Code	250
Min. Negotiated Rate	$55.16
Max. Negotiated Rate	$127.39
Rate for Payer: AlohaCare Medicaid	$65.67
Rate for Payer: AlohaCare Medicare	$55.16
Rate for Payer: Cash Price	$85.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$120.82
Rate for Payer: Devoted Health Medicare	$55.16
Rate for Payer: Hawaii Medical Service Association Medicare	$55.16
Rate for Payer: Hawaii Western Management Group Commercial	$124.76
Rate for Payer: Health Management Network Commercial	$111.63
Rate for Payer: Humana Medicare	$55.16
Rate for Payer: Kaiser Permanente Commercial	$118.20
Rate for Payer: Kaiser Permanente Medicaid	$66.98
Rate for Payer: Kaiser Permanente Medicare	$55.16
Rate for Payer: MDX Hawaii PPO	$127.39
Rate for Payer: Ohana Health Plan Medicaid	$55.16
Rate for Payer: Ohana Health Plan Medicare	$55.16
Rate for Payer: UnitedHealthcare Medicaid	$78.80
Rate for Payer: UnitedHealthcare Medicare	$55.16
Rate for Payer: University Health Alliance Commercial	$95.73

patiromer 8.4 gm packets [KMC]

Facility

$131.33

Service Code	NDC 53436008430
Hospital Revenue Code	250
Min. Negotiated Rate	$111.63
Max. Negotiated Rate	$127.39
Rate for Payer: Cash Price	$85.36
Rate for Payer: Health Management Network Commercial	$111.63
Rate for Payer: Kaiser Permanente Commercial	$118.20
Rate for Payer: MDX Hawaii PPO	$127.39

PCV13 VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$0.01

Service Code	HCPCS 90670 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$218.03
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	$218.03
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

PCV13 VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$298.00

Service Code	HCPCS 90670
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$253.30
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$193.70
Rate for Payer: Cash Price	$193.70
Rate for Payer: Hawaii Western Management Group Commercial	$218.03
Rate for Payer: Health Management Network Commercial	$253.30
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

PCV20 VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$552.00

Service Code	HCPCS 90677
Hospital Revenue Code	636
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$469.20
Rate for Payer: AlohaCare Medicare	$312.90
Rate for Payer: Cash Price	$358.80
Rate for Payer: Cash Price	$358.80
Rate for Payer: Devoted Health Medicare	$312.90
Rate for Payer: Hawaii Medical Service Association Medicare	$312.90
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Kaiser Permanente Commercial	$375.48
Rate for Payer: Kaiser Permanente Medicaid	$375.48
Rate for Payer: Kaiser Permanente Medicare	$375.48
Rate for Payer: Ohana Health Plan Medicare	$312.90
Rate for Payer: UnitedHealthcare Medicare	$312.90

PCV20 VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$0.01

Service Code	HCPCS 90677 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

Peak Flow

Facility

$9.00

Hospital Charge Code	10004
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

Peak Flow

Facility

$9.00

Hospital Charge Code	10004
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

PED NON REBREATHING ELONGATED

Facility

$39.00

Hospital Charge Code	8429
Hospital Revenue Code	270
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$37.83
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$16.38
Rate for Payer: Cash Price	$25.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$35.88
Rate for Payer: Devoted Health Medicare	$16.38
Rate for Payer: Hawaii Medical Service Association Medicare	$16.38
Rate for Payer: Hawaii Western Management Group Commercial	$37.05
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Humana Medicare	$16.38
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicare	$16.38
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$16.38
Rate for Payer: UnitedHealthcare Medicare	$16.38
Rate for Payer: University Health Alliance Commercial	$28.43

PED NON REBREATHING ELONGATED

Facility

$39.00

Hospital Charge Code	8429
Hospital Revenue Code	270
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$25.35
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83

PED ROOM BOARD PVT

Facility

$2,281.00

Hospital Charge Code	1401001
Hospital Revenue Code	113
Min. Negotiated Rate	$1,938.85
Max. Negotiated Rate	$7,250.00
Rate for Payer: AlohaCare Medicaid	$2,811.74
Rate for Payer: AlohaCare Medicare	$2,638.00
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,803.60
Rate for Payer: Devoted Health Medicare	$2,638.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2,811.74
Rate for Payer: Hawaii Medical Service Association Medicare	$2,638.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$1,938.85
Rate for Payer: Humana Medicare	$2,638.00
Rate for Payer: Kaiser Permanente Commercial	$2,052.90
Rate for Payer: Kaiser Permanente Medicaid	$2,811.74
Rate for Payer: Kaiser Permanente Medicare	$2,638.00
Rate for Payer: MDX Hawaii PPO	$2,212.57
Rate for Payer: Ohana Health Plan Medicaid	$2,811.74
Rate for Payer: Ohana Health Plan Medicare	$2,638.00
Rate for Payer: UnitedHealthcare Medicaid	$2,811.74
Rate for Payer: UnitedHealthcare Medicare	$2,638.00
Rate for Payer: University Health Alliance Commercial	$5,923.00

PELV HIP INF CHLD MIN 2V

Facility

$369.00

Service Code	HCPCS 73503
Hospital Charge Code	424735030
Hospital Revenue Code	320
Min. Negotiated Rate	$25.86
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	$25.86
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	$40.27
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$123.25

PELV HIP INF CHLD MIN 2V

Facility

$369.00

Service Code	HCPCS 73503
Hospital Charge Code	424735030
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

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$39,487.53

Service Code	MSDRG 734
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$39,487.53

Service Code	MSDRG 735
Min. Negotiated Rate	$39,487.53
Max. Negotiated Rate	$39,487.53
Rate for Payer: Hawaii Medical Service Association Commercial	$39,487.53

PELVIS 1 2 VWS

Facility

$369.00

Service Code	HCPCS 72170
Hospital Charge Code	424721700
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

PELVIS 1 2 VWS

Facility

$369.00

Service Code	HCPCS 72170
Hospital Charge Code	424721700
Hospital Revenue Code	320
Min. Negotiated Rate	$18.74
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	$18.74
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	$18.74
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$55.37

PELVIS COMP MIN 3 VWS

Facility

$369.00

Service Code	HCPCS 72190
Hospital Charge Code	424721900
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
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	$21.96
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	$21.96
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$78.55

PELVIS COMP MIN 3 VWS

Facility

$369.00

Service Code	HCPCS 72190
Hospital Charge Code	424721900
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

penicillin G benzathine 1,200,000 units/2 mL Sus [KMC]

Facility

$499.95

Service Code	HCPCS J0561
Hospital Revenue Code	636
Min. Negotiated Rate	$29.30
Max. Negotiated Rate	$484.95
Rate for Payer: AlohaCare Medicaid	$249.97
Rate for Payer: AlohaCare Medicare	$209.98
Rate for Payer: Cash Price	$324.97
Rate for Payer: Cash Price	$324.97
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$459.95
Rate for Payer: Devoted Health Medicare	$209.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$29.30
Rate for Payer: Hawaii Medical Service Association Commercial	$39.34
Rate for Payer: Hawaii Medical Service Association Medicare	$209.98
Rate for Payer: Hawaii Western Management Group Commercial	$474.95
Rate for Payer: Health Management Network Commercial	$424.96
Rate for Payer: Humana Medicare	$209.98
Rate for Payer: Kaiser Permanente Commercial	$449.95
Rate for Payer: Kaiser Permanente Medicaid	$254.97
Rate for Payer: Kaiser Permanente Medicare	$209.98
Rate for Payer: MDX Hawaii PPO	$484.95
Rate for Payer: Ohana Health Plan Medicaid	$209.98
Rate for Payer: Ohana Health Plan Medicare	$209.98
Rate for Payer: UnitedHealthcare Medicaid	$299.97
Rate for Payer: UnitedHealthcare Medicare	$209.98
Rate for Payer: University Health Alliance Commercial	$364.41

penicillin G benzathine 1,200,000 units/2 mL Sus [KMC]

Facility

$499.95

Service Code	HCPCS J0561
Hospital Revenue Code	636
Min. Negotiated Rate	$424.96
Max. Negotiated Rate	$484.95
Rate for Payer: Cash Price	$324.97
Rate for Payer: Health Management Network Commercial	$424.96
Rate for Payer: Kaiser Permanente Commercial	$449.95
Rate for Payer: MDX Hawaii PPO	$484.95

PENICILLIN G BENZATHINE INJ

Professional

Both

$146.00

Service Code	HCPCS J0561
Hospital Revenue Code	636
Min. Negotiated Rate	$16.36
Max. Negotiated Rate	$124.10
Rate for Payer: AlohaCare Medicare	$31.47
Rate for Payer: Cash Price	$94.90
Rate for Payer: Cash Price	$94.90
Rate for Payer: Devoted Health Medicare	$31.47
Rate for Payer: Hawaii Medical Service Association Medicare	$31.47
Rate for Payer: Hawaii Western Management Group Commercial	$16.36
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$37.76
Rate for Payer: Kaiser Permanente Medicaid	$37.76
Rate for Payer: Kaiser Permanente Medicare	$37.76
Rate for Payer: Ohana Health Plan Medicare	$31.47
Rate for Payer: UnitedHealthcare Medicare	$31.47

Know your out-of-pocket cost for care.

All Charges