Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

PNEUMOCOCCAL VACCINE ADMIN RCVD PRIOR

Professional

Both

$0.01

Service Code	HCPCS 4040F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
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: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
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: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PNEUMOTHORAX WITH CC

Facility

$17,373.57

Service Code	MSDRG 200
Min. Negotiated Rate	$17,373.57
Max. Negotiated Rate	$17,373.57
Rate for Payer: Hawaii Medical Service Association Commercial	$17,373.57

PNEUMOTHORAX WITH MCC

Facility

$18,321.65

Service Code	MSDRG 199
Min. Negotiated Rate	$18,321.65
Max. Negotiated Rate	$18,321.65
Rate for Payer: Hawaii Medical Service Association Commercial	$18,321.65

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$13,770.86

Service Code	MSDRG 201
Min. Negotiated Rate	$13,770.86
Max. Negotiated Rate	$13,770.86
Rate for Payer: Hawaii Medical Service Association Commercial	$13,770.86

PNEUMOVAX 23 Vaccine [KMC]

Facility

$1,123.98

Service Code	NDC 00006483703
Hospital Revenue Code	250
Min. Negotiated Rate	$472.07
Max. Negotiated Rate	$1,090.26
Rate for Payer: AlohaCare Medicaid	$561.99
Rate for Payer: AlohaCare Medicare	$472.07
Rate for Payer: Cash Price	$730.59
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,034.06
Rate for Payer: Devoted Health Medicare	$472.07
Rate for Payer: Hawaii Medical Service Association Medicare	$472.07
Rate for Payer: Hawaii Western Management Group Commercial	$1,067.78
Rate for Payer: Health Management Network Commercial	$955.38
Rate for Payer: Humana Medicare	$472.07
Rate for Payer: Kaiser Permanente Commercial	$1,011.58
Rate for Payer: Kaiser Permanente Medicaid	$573.23
Rate for Payer: Kaiser Permanente Medicare	$472.07
Rate for Payer: MDX Hawaii PPO	$1,090.26
Rate for Payer: Ohana Health Plan Medicaid	$472.07
Rate for Payer: Ohana Health Plan Medicare	$472.07
Rate for Payer: UnitedHealthcare Medicaid	$674.39
Rate for Payer: UnitedHealthcare Medicare	$472.07
Rate for Payer: University Health Alliance Commercial	$819.27

PNEUMOVAX 23 Vaccine [KMC]

Facility

$1,123.98

Service Code	NDC 00006483703
Hospital Revenue Code	250
Min. Negotiated Rate	$955.38
Max. Negotiated Rate	$1,090.26
Rate for Payer: Cash Price	$730.59
Rate for Payer: Health Management Network Commercial	$955.38
Rate for Payer: Kaiser Permanente Commercial	$1,011.58
Rate for Payer: MDX Hawaii PPO	$1,090.26

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$20,597.04

Service Code	MSDRG 917
Min. Negotiated Rate	$20,597.04
Max. Negotiated Rate	$20,597.04
Rate for Payer: Hawaii Medical Service Association Commercial	$20,597.04

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$15,714.43

Service Code	MSDRG 918
Min. Negotiated Rate	$15,714.43
Max. Negotiated Rate	$15,714.43
Rate for Payer: Hawaii Medical Service Association Commercial	$15,714.43

POLIOVIRUS VACCINE INACTIVATED SUBQ/IM

Professional

Both

$0.01

Service Code	HCPCS 90713 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$33.41
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	$33.41
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

POLIOVIRUS VACCINE INACTIVATED SUBQ/IM

Professional

Both

$138.00

Service Code	HCPCS 90713
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$117.30
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Hawaii Western Management Group Commercial	$33.41
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

polycarbophil 625 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 49348075913
Hospital Revenue Code	250
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

polycarbophil 625 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 49348075913
Hospital Revenue Code	250
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 Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

polyethylene glycol 3350 (Miralax packet) [KMC]

Facility

$6.79

Service Code	NDC 72603030203
Hospital Revenue Code	250
Min. Negotiated Rate	$5.77
Max. Negotiated Rate	$6.59
Rate for Payer: Cash Price	$4.41
Rate for Payer: Health Management Network Commercial	$5.77
Rate for Payer: Kaiser Permanente Commercial	$6.11
Rate for Payer: MDX Hawaii PPO	$6.59

polyethylene glycol 3350 (Miralax packet) [KMC]

Facility

$6.79

Service Code	NDC 72603030203
Hospital Revenue Code	250
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$6.59
Rate for Payer: AlohaCare Medicaid	$3.40
Rate for Payer: AlohaCare Medicare	$2.85
Rate for Payer: Cash Price	$4.41
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.25
Rate for Payer: Devoted Health Medicare	$2.85
Rate for Payer: Hawaii Medical Service Association Medicare	$2.85
Rate for Payer: Hawaii Western Management Group Commercial	$6.45
Rate for Payer: Health Management Network Commercial	$5.77
Rate for Payer: Humana Medicare	$2.85
Rate for Payer: Kaiser Permanente Commercial	$6.11
Rate for Payer: Kaiser Permanente Medicaid	$3.46
Rate for Payer: Kaiser Permanente Medicare	$2.85
Rate for Payer: MDX Hawaii PPO	$6.59
Rate for Payer: Ohana Health Plan Medicaid	$2.85
Rate for Payer: Ohana Health Plan Medicare	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$4.07
Rate for Payer: UnitedHealthcare Medicare	$2.85
Rate for Payer: University Health Alliance Commercial	$4.95

polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln [KMC]

Facility

$5.38

Service Code	NDC 24208031510
Hospital Revenue Code	250
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$5.22
Rate for Payer: AlohaCare Medicaid	$2.69
Rate for Payer: AlohaCare Medicare	$2.26
Rate for Payer: Cash Price	$3.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.95
Rate for Payer: Devoted Health Medicare	$2.26
Rate for Payer: Hawaii Medical Service Association Medicare	$2.26
Rate for Payer: Hawaii Western Management Group Commercial	$5.11
Rate for Payer: Health Management Network Commercial	$4.57
Rate for Payer: Humana Medicare	$2.26
Rate for Payer: Kaiser Permanente Commercial	$4.84
Rate for Payer: Kaiser Permanente Medicaid	$2.74
Rate for Payer: Kaiser Permanente Medicare	$2.26
Rate for Payer: MDX Hawaii PPO	$5.22
Rate for Payer: Ohana Health Plan Medicaid	$2.26
Rate for Payer: Ohana Health Plan Medicare	$2.26
Rate for Payer: UnitedHealthcare Medicaid	$3.23
Rate for Payer: UnitedHealthcare Medicare	$2.26
Rate for Payer: University Health Alliance Commercial	$3.92

polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln [KMC]

Facility

$5.38

Service Code	NDC 24208031510
Hospital Revenue Code	250
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$5.22
Rate for Payer: Cash Price	$3.50
Rate for Payer: Health Management Network Commercial	$4.57
Rate for Payer: Kaiser Permanente Commercial	$4.84
Rate for Payer: MDX Hawaii PPO	$5.22

posaconazole 100 mg DR Tab [KMC]

Facility

$296.03

Service Code	NDC 70748025807
Hospital Revenue Code	250
Min. Negotiated Rate	$124.33
Max. Negotiated Rate	$287.15
Rate for Payer: AlohaCare Medicaid	$148.01
Rate for Payer: AlohaCare Medicare	$124.33
Rate for Payer: Cash Price	$192.42
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$272.35
Rate for Payer: Devoted Health Medicare	$124.33
Rate for Payer: Hawaii Medical Service Association Medicare	$124.33
Rate for Payer: Hawaii Western Management Group Commercial	$281.23
Rate for Payer: Health Management Network Commercial	$251.63
Rate for Payer: Humana Medicare	$124.33
Rate for Payer: Kaiser Permanente Commercial	$266.43
Rate for Payer: Kaiser Permanente Medicaid	$150.98
Rate for Payer: Kaiser Permanente Medicare	$124.33
Rate for Payer: MDX Hawaii PPO	$287.15
Rate for Payer: Ohana Health Plan Medicaid	$124.33
Rate for Payer: Ohana Health Plan Medicare	$124.33
Rate for Payer: UnitedHealthcare Medicaid	$177.62
Rate for Payer: UnitedHealthcare Medicare	$124.33
Rate for Payer: University Health Alliance Commercial	$215.78

posaconazole 100 mg DR Tab [KMC]

Facility

$296.03

Service Code	NDC 70748025807
Hospital Revenue Code	250
Min. Negotiated Rate	$251.63
Max. Negotiated Rate	$287.15
Rate for Payer: Cash Price	$192.42
Rate for Payer: Health Management Network Commercial	$251.63
Rate for Payer: Kaiser Permanente Commercial	$266.43
Rate for Payer: MDX Hawaii PPO	$287.15

posaconazole 200 mg/ 5 mL Susp [KMC]

Facility

$62.33

Service Code	NDC 00085132801
Hospital Revenue Code	250
Min. Negotiated Rate	$26.18
Max. Negotiated Rate	$60.46
Rate for Payer: AlohaCare Medicaid	$31.16
Rate for Payer: AlohaCare Medicare	$26.18
Rate for Payer: Cash Price	$40.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$57.34
Rate for Payer: Devoted Health Medicare	$26.18
Rate for Payer: Hawaii Medical Service Association Medicare	$26.18
Rate for Payer: Hawaii Western Management Group Commercial	$59.21
Rate for Payer: Health Management Network Commercial	$52.98
Rate for Payer: Humana Medicare	$26.18
Rate for Payer: Kaiser Permanente Commercial	$56.10
Rate for Payer: Kaiser Permanente Medicaid	$31.79
Rate for Payer: Kaiser Permanente Medicare	$26.18
Rate for Payer: MDX Hawaii PPO	$60.46
Rate for Payer: Ohana Health Plan Medicaid	$26.18
Rate for Payer: Ohana Health Plan Medicare	$26.18
Rate for Payer: UnitedHealthcare Medicaid	$37.40
Rate for Payer: UnitedHealthcare Medicare	$26.18
Rate for Payer: University Health Alliance Commercial	$45.43

posaconazole 200 mg/ 5 mL Susp [KMC]

Facility

$62.33

Service Code	NDC 00085132801
Hospital Revenue Code	250
Min. Negotiated Rate	$52.98
Max. Negotiated Rate	$60.46
Rate for Payer: Cash Price	$40.51
Rate for Payer: Health Management Network Commercial	$52.98
Rate for Payer: Kaiser Permanente Commercial	$56.10
Rate for Payer: MDX Hawaii PPO	$60.46

POSITIVE MACROALBUMINURIA TEST RESULT DOC&REV

Professional

Both

$0.01

Service Code	HCPCS 3062F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
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: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

POSITIVE MICROALBUMINURIA TEST RESULT DOC&REV

Professional

Both

$0.01

Service Code	HCPCS 3060F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$21,545.12

Service Code	MSDRG 862
Min. Negotiated Rate	$21,545.12
Max. Negotiated Rate	$21,545.12
Rate for Payer: Hawaii Medical Service Association Commercial	$21,545.12

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$21,545.12

Service Code	MSDRG 863
Min. Negotiated Rate	$21,545.12
Max. Negotiated Rate	$21,545.12
Rate for Payer: Hawaii Medical Service Association Commercial	$21,545.12

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$37,899.50

Service Code	MSDRG 857
Min. Negotiated Rate	$37,899.50
Max. Negotiated Rate	$37,899.50
Rate for Payer: Hawaii Medical Service Association Commercial	$37,899.50

Know your out-of-pocket cost for care.

All Charges