Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

PERINEAL IRRIGATION BTL

Facility

$61.00

Hospital Charge Code	8240
Hospital Revenue Code	270
Min. Negotiated Rate	$25.62
Max. Negotiated Rate	$59.17
Rate for Payer: AlohaCare Medicaid	$30.50
Rate for Payer: AlohaCare Medicare	$25.62
Rate for Payer: Cash Price	$39.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$56.12
Rate for Payer: Devoted Health Medicare	$25.62
Rate for Payer: Hawaii Medical Service Association Medicare	$25.62
Rate for Payer: Hawaii Western Management Group Commercial	$57.95
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Humana Medicare	$25.62
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: Kaiser Permanente Medicare	$25.62
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: Ohana Health Plan Medicaid	$25.62
Rate for Payer: Ohana Health Plan Medicare	$25.62
Rate for Payer: UnitedHealthcare Medicare	$25.62
Rate for Payer: University Health Alliance Commercial	$44.46

PERINEAL IRRIGATION BTL

Facility

$61.00

Hospital Charge Code	8240
Hospital Revenue Code	270
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$39.65
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$54.90
Rate for Payer: MDX Hawaii PPO	$59.17

PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1Y

Professional

Both

$259.00

Service Code	HCPCS 99391
Hospital Revenue Code	521
Min. Negotiated Rate	$43.71
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$67.37
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
Rate for Payer: Cash Price	$168.35
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$43.71
Rate for Payer: Health Management Network Commercial	$220.15
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$67.37
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PERIODIC PREVENTIVE MED EST PATIENT 12-17YRS

Professional

Both

$317.00

Service Code	HCPCS 99394
Hospital Revenue Code	521
Min. Negotiated Rate	$58.30
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$83.70
Rate for Payer: Cash Price	$206.05
Rate for Payer: Cash Price	$206.05
Rate for Payer: Cash Price	$206.05
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$58.30
Rate for Payer: Health Management Network Commercial	$269.45
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$83.70
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PERIODIC PREVENTIVE MED EST PATIENT 1-4YRS

Professional

Both

$283.00

Service Code	HCPCS 99392
Hospital Revenue Code	521
Min. Negotiated Rate	$47.38
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$73.80
Rate for Payer: Cash Price	$183.95
Rate for Payer: Cash Price	$183.95
Rate for Payer: Cash Price	$183.95
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$47.38
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$73.80
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PERIODIC PREVENTIVE MED EST PATIENT 18-39 YRS

Professional

Both

$325.00

Service Code	HCPCS 99395
Hospital Revenue Code	521
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$86.32
Rate for Payer: Cash Price	$211.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$64.63
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$86.32
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS

Professional

Both

$354.00

Service Code	HCPCS 99396
Hospital Revenue Code	521
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$300.90
Rate for Payer: AlohaCare Medicaid	$93.79
Rate for Payer: Cash Price	$230.10
Rate for Payer: Cash Price	$230.10
Rate for Payer: Cash Price	$230.10
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$64.63
Rate for Payer: Health Management Network Commercial	$300.90
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$93.79
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PERIODIC PREVENTIVE MED EST PATIENT 5-11YRS

Professional

Both

$283.00

Service Code	HCPCS 99393
Hospital Revenue Code	521
Min. Negotiated Rate	$52.48
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$73.80
Rate for Payer: Cash Price	$183.95
Rate for Payer: Cash Price	$183.95
Rate for Payer: Cash Price	$183.95
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$52.48
Rate for Payer: Health Management Network Commercial	$240.55
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$73.80
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PERIODIC PREVENTIVE MED EST PATIENT 65YRS& OLDER

Professional

Both

$277.00

Service Code	HCPCS 99397
Hospital Revenue Code	521
Min. Negotiated Rate	$64.63
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$98.65
Rate for Payer: Cash Price	$180.05
Rate for Payer: Cash Price	$180.05
Rate for Payer: Cash Price	$180.05
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$64.63
Rate for Payer: Health Management Network Commercial	$235.45
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$98.65
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR

Facility

$58,093.60

Service Code	MSDRG 041
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$58,093.60
Rate for Payer: Hawaii Medical Service Association Commercial	$58,093.60
Rate for Payer: University Health Alliance Commercial	$10,400.00

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC

Facility

$66,057.47

Service Code	MSDRG 040
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$66,057.47
Rate for Payer: Hawaii Medical Service Association Commercial	$66,057.47
Rate for Payer: University Health Alliance Commercial	$10,400.00

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC

Facility

$50,106.03

Service Code	MSDRG 042
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$50,106.03
Rate for Payer: Hawaii Medical Service Association Commercial	$50,106.03
Rate for Payer: University Health Alliance Commercial	$10,400.00

PERIPHERAL VASCULAR DISORDERS WITH CC

Facility

$24,531.57

Service Code	MSDRG 300
Min. Negotiated Rate	$24,531.57
Max. Negotiated Rate	$24,531.57
Rate for Payer: Hawaii Medical Service Association Commercial	$24,531.57

PERIPHERAL VASCULAR DISORDERS WITH MCC

Facility

$26,024.80

Service Code	MSDRG 299
Min. Negotiated Rate	$26,024.80
Max. Negotiated Rate	$26,024.80
Rate for Payer: Hawaii Medical Service Association Commercial	$26,024.80

PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC

Facility

$18,060.92

Service Code	MSDRG 301
Min. Negotiated Rate	$18,060.92
Max. Negotiated Rate	$18,060.92
Rate for Payer: Hawaii Medical Service Association Commercial	$18,060.92

PERITONEAL ADHESIOLYSIS WITH CC

Facility

$53,400.61

Service Code	MSDRG 336
Min. Negotiated Rate	$53,400.61
Max. Negotiated Rate	$53,400.61
Rate for Payer: Hawaii Medical Service Association Commercial	$53,400.61

PERITONEAL ADHESIOLYSIS WITH MCC

Facility

$60,416.40

Service Code	MSDRG 335
Min. Negotiated Rate	$60,416.40
Max. Negotiated Rate	$60,416.40
Rate for Payer: Hawaii Medical Service Association Commercial	$60,416.40

PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC

Facility

$32,779.87

Service Code	MSDRG 337
Min. Negotiated Rate	$32,779.87
Max. Negotiated Rate	$32,779.87
Rate for Payer: Hawaii Medical Service Association Commercial	$32,779.87

PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC

Facility

$53,519.12

Service Code	MSDRG 243
Min. Negotiated Rate	$53,519.12
Max. Negotiated Rate	$53,519.12
Rate for Payer: Hawaii Medical Service Association Commercial	$53,519.12

PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC

Facility

$71,580.04

Service Code	MSDRG 242
Min. Negotiated Rate	$71,580.04
Max. Negotiated Rate	$71,580.04
Rate for Payer: Hawaii Medical Service Association Commercial	$71,580.04

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC

Facility

$43,967.21

Service Code	MSDRG 244
Min. Negotiated Rate	$43,967.21
Max. Negotiated Rate	$43,967.21
Rate for Payer: Hawaii Medical Service Association Commercial	$43,967.21

permethrin 1% Lotion [KMC]

Facility

$0.72

Service Code	NDC 49348015078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.70
Rate for Payer: AlohaCare Medicaid	$0.36
Rate for Payer: AlohaCare Medicare	$0.30
Rate for Payer: Cash Price	$0.47
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.66
Rate for Payer: Devoted Health Medicare	$0.30
Rate for Payer: Hawaii Medical Service Association Medicare	$0.30
Rate for Payer: Hawaii Western Management Group Commercial	$0.68
Rate for Payer: Health Management Network Commercial	$0.61
Rate for Payer: Humana Medicare	$0.30
Rate for Payer: Kaiser Permanente Commercial	$0.65
Rate for Payer: Kaiser Permanente Medicaid	$0.37
Rate for Payer: Kaiser Permanente Medicare	$0.30
Rate for Payer: MDX Hawaii PPO	$0.70
Rate for Payer: Ohana Health Plan Medicaid	$0.30
Rate for Payer: Ohana Health Plan Medicare	$0.30
Rate for Payer: UnitedHealthcare Medicaid	$0.43
Rate for Payer: UnitedHealthcare Medicare	$0.30
Rate for Payer: University Health Alliance Commercial	$0.52

permethrin 1% Lotion [KMC]

Facility

$0.72

Service Code	NDC 49348015078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.47
Rate for Payer: Health Management Network Commercial	$0.61
Rate for Payer: Kaiser Permanente Commercial	$0.65
Rate for Payer: MDX Hawaii PPO	$0.70

permethrin 5% Cream [KMC]

Facility

$8.08

Service Code	NDC 16714089701
Hospital Revenue Code	250
Min. Negotiated Rate	$6.87
Max. Negotiated Rate	$7.84
Rate for Payer: Cash Price	$5.25
Rate for Payer: Health Management Network Commercial	$6.87
Rate for Payer: Kaiser Permanente Commercial	$7.27
Rate for Payer: MDX Hawaii PPO	$7.84

permethrin 5% Cream [KMC]

Facility

$8.08

Service Code	NDC 16714089701
Hospital Revenue Code	250
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$7.84
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$3.39
Rate for Payer: Cash Price	$5.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.43
Rate for Payer: Devoted Health Medicare	$3.39
Rate for Payer: Hawaii Medical Service Association Medicare	$3.39
Rate for Payer: Hawaii Western Management Group Commercial	$7.68
Rate for Payer: Health Management Network Commercial	$6.87
Rate for Payer: Humana Medicare	$3.39
Rate for Payer: Kaiser Permanente Commercial	$7.27
Rate for Payer: Kaiser Permanente Medicaid	$4.12
Rate for Payer: Kaiser Permanente Medicare	$3.39
Rate for Payer: MDX Hawaii PPO	$7.84
Rate for Payer: Ohana Health Plan Medicaid	$3.39
Rate for Payer: Ohana Health Plan Medicare	$3.39
Rate for Payer: UnitedHealthcare Medicaid	$4.85
Rate for Payer: UnitedHealthcare Medicare	$3.39
Rate for Payer: University Health Alliance Commercial	$5.89

Know your out-of-pocket cost for care.

All Charges