Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

ANTI EMOBISM STOCKING XL

Facility

$4.00

Hospital Charge Code	8022
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

ANTI EMOBISM STOCKING XL

Facility

$4.00

Hospital Charge Code	8022
Hospital Revenue Code	270
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

Anti-Nuclear Ab, Serum DLS

Facility

$153.00

Service Code	HCPCS 86038
Hospital Charge Code	422860385
Hospital Revenue Code	301
Min. Negotiated Rate	$12.09
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$64.26
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cash Price	$99.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$140.76
Rate for Payer: Devoted Health Medicare	$64.26
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.70
Rate for Payer: Hawaii Medical Service Association Commercial	$15.11
Rate for Payer: Hawaii Medical Service Association Medicare	$64.26
Rate for Payer: Hawaii Western Management Group Commercial	$12.09
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$64.26
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$64.26
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$64.26
Rate for Payer: Ohana Health Plan Medicare	$64.26
Rate for Payer: UnitedHealthcare Medicaid	$16.70
Rate for Payer: UnitedHealthcare Medicare	$64.26
Rate for Payer: University Health Alliance Commercial	$31.25

Anti-Nuclear Ab, Serum DLS

Facility

$153.00

Service Code	HCPCS 86038
Hospital Charge Code	422860385
Hospital Revenue Code	301
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$99.45
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

antipyrine-benzocaine Otic Sol [KMC]

Facility

$4.78

Service Code	NDC 24208056162
Hospital Revenue Code	250
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$4.64
Rate for Payer: AlohaCare Medicaid	$2.39
Rate for Payer: AlohaCare Medicare	$2.01
Rate for Payer: Cash Price	$3.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.40
Rate for Payer: Devoted Health Medicare	$2.01
Rate for Payer: Hawaii Medical Service Association Medicare	$2.01
Rate for Payer: Hawaii Western Management Group Commercial	$4.54
Rate for Payer: Health Management Network Commercial	$4.06
Rate for Payer: Humana Medicare	$2.01
Rate for Payer: Kaiser Permanente Commercial	$4.30
Rate for Payer: Kaiser Permanente Medicaid	$2.44
Rate for Payer: Kaiser Permanente Medicare	$2.01
Rate for Payer: MDX Hawaii PPO	$4.64
Rate for Payer: Ohana Health Plan Medicaid	$2.01
Rate for Payer: Ohana Health Plan Medicare	$2.01
Rate for Payer: UnitedHealthcare Medicaid	$2.87
Rate for Payer: UnitedHealthcare Medicare	$2.01
Rate for Payer: University Health Alliance Commercial	$3.48

antipyrine-benzocaine Otic Sol [KMC]

Facility

$4.78

Service Code	NDC 24208056162
Hospital Revenue Code	250
Min. Negotiated Rate	$4.06
Max. Negotiated Rate	$4.64
Rate for Payer: Cash Price	$3.11
Rate for Payer: Health Management Network Commercial	$4.06
Rate for Payer: Kaiser Permanente Commercial	$4.30
Rate for Payer: MDX Hawaii PPO	$4.64

Anti-SSA/RO DLS

Facility

$59.00

Service Code	HCPCS 86235
Hospital Charge Code	422862355
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$57.23
Rate for Payer: AlohaCare Medicaid	$29.50
Rate for Payer: AlohaCare Medicare	$24.78
Rate for Payer: Cash Price	$38.35
Rate for Payer: Cash Price	$38.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$54.28
Rate for Payer: Devoted Health Medicare	$24.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$24.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Humana Medicare	$24.78
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicare	$24.78
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: Ohana Health Plan Medicaid	$24.78
Rate for Payer: Ohana Health Plan Medicare	$24.78
Rate for Payer: UnitedHealthcare Medicaid	$24.78
Rate for Payer: UnitedHealthcare Medicare	$24.78
Rate for Payer: University Health Alliance Commercial	$46.36

Anti-SSA/RO DLS

Facility

$59.00

Service Code	HCPCS 86235
Hospital Charge Code	422862355
Hospital Revenue Code	302
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$38.35
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: MDX Hawaii PPO	$57.23

Anti-SSB/LA DLS

Facility

$59.00

Service Code	HCPCS 86235
Hospital Charge Code	422862355
Hospital Revenue Code	302
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$38.35
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: MDX Hawaii PPO	$57.23

Anti-SSB/LA DLS

Facility

$59.00

Service Code	HCPCS 86235
Hospital Charge Code	422862355
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$57.23
Rate for Payer: AlohaCare Medicaid	$29.50
Rate for Payer: AlohaCare Medicare	$24.78
Rate for Payer: Cash Price	$38.35
Rate for Payer: Cash Price	$38.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$54.28
Rate for Payer: Devoted Health Medicare	$24.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$24.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Humana Medicare	$24.78
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicare	$24.78
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: Ohana Health Plan Medicaid	$24.78
Rate for Payer: Ohana Health Plan Medicare	$24.78
Rate for Payer: UnitedHealthcare Medicaid	$24.78
Rate for Payer: UnitedHealthcare Medicare	$24.78
Rate for Payer: University Health Alliance Commercial	$46.36

Anti-Streptolysin O DLS

Facility

$47.00

Service Code	HCPCS 86060
Hospital Charge Code	422860605
Hospital Revenue Code	301
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$30.55
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: MDX Hawaii PPO	$45.59

Anti-Streptolysin O DLS

Facility

$47.00

Service Code	HCPCS 86060
Hospital Charge Code	422860605
Hospital Revenue Code	301
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$45.59
Rate for Payer: AlohaCare Medicaid	$23.50
Rate for Payer: AlohaCare Medicare	$19.74
Rate for Payer: Cash Price	$30.55
Rate for Payer: Cash Price	$30.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$43.24
Rate for Payer: Devoted Health Medicare	$19.74
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$10.09
Rate for Payer: Hawaii Medical Service Association Commercial	$9.12
Rate for Payer: Hawaii Medical Service Association Medicare	$19.74
Rate for Payer: Hawaii Western Management Group Commercial	$7.30
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Humana Medicare	$19.74
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: Kaiser Permanente Medicare	$19.74
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: Ohana Health Plan Medicaid	$19.74
Rate for Payer: Ohana Health Plan Medicare	$19.74
Rate for Payer: UnitedHealthcare Medicaid	$10.09
Rate for Payer: UnitedHealthcare Medicare	$19.74
Rate for Payer: University Health Alliance Commercial	$18.87

Anti-Thyroglobulin Ab DLS

Facility

$217.00

Service Code	HCPCS 86800
Hospital Charge Code	422868005
Hospital Revenue Code	301
Min. Negotiated Rate	$184.45
Max. Negotiated Rate	$210.49
Rate for Payer: Cash Price	$141.05
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: Kaiser Permanente Commercial	$195.30
Rate for Payer: MDX Hawaii PPO	$210.49

Anti-Thyroglobulin Ab DLS

Facility

$217.00

Service Code	HCPCS 86800
Hospital Charge Code	422868005
Hospital Revenue Code	301
Min. Negotiated Rate	$15.91
Max. Negotiated Rate	$210.49
Rate for Payer: AlohaCare Medicaid	$108.50
Rate for Payer: AlohaCare Medicare	$91.14
Rate for Payer: Cash Price	$141.05
Rate for Payer: Cash Price	$141.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$199.64
Rate for Payer: Devoted Health Medicare	$91.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$21.98
Rate for Payer: Hawaii Medical Service Association Commercial	$19.89
Rate for Payer: Hawaii Medical Service Association Medicare	$91.14
Rate for Payer: Hawaii Western Management Group Commercial	$15.91
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: Humana Medicare	$91.14
Rate for Payer: Kaiser Permanente Commercial	$195.30
Rate for Payer: Kaiser Permanente Medicaid	$110.67
Rate for Payer: Kaiser Permanente Medicare	$91.14
Rate for Payer: MDX Hawaii PPO	$210.49
Rate for Payer: Ohana Health Plan Medicaid	$91.14
Rate for Payer: Ohana Health Plan Medicare	$91.14
Rate for Payer: UnitedHealthcare Medicaid	$21.98
Rate for Payer: UnitedHealthcare Medicare	$91.14
Rate for Payer: University Health Alliance Commercial	$41.11

Anti-TPO Microsomal DLS

Facility

$54.00

Service Code	HCPCS 86376
Hospital Charge Code	422863765
Hospital Revenue Code	302
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

Anti-TPO Microsomal DLS

Facility

$54.00

Service Code	HCPCS 86376
Hospital Charge Code	422863765
Hospital Revenue Code	302
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$22.68
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$49.68
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.11
Rate for Payer: Hawaii Medical Service Association Commercial	$18.19
Rate for Payer: Hawaii Medical Service Association Medicare	$22.68
Rate for Payer: Hawaii Western Management Group Commercial	$14.55
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$22.68
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$22.68
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$22.68
Rate for Payer: Ohana Health Plan Medicare	$22.68
Rate for Payer: UnitedHealthcare Medicaid	$20.11
Rate for Payer: UnitedHealthcare Medicare	$22.68
Rate for Payer: University Health Alliance Commercial	$37.61

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC

Facility

$111,280.89

Service Code	MSDRG 268
Min. Negotiated Rate	$111,280.89
Max. Negotiated Rate	$111,280.89
Rate for Payer: Hawaii Medical Service Association Commercial	$111,280.89

AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC

Facility

$96,040.50

Service Code	MSDRG 269
Min. Negotiated Rate	$96,040.50
Max. Negotiated Rate	$96,040.50
Rate for Payer: Hawaii Medical Service Association Commercial	$96,040.50

apixaban 2.5 mg Tab [KMC]

Facility

$21.23

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$8.92
Max. Negotiated Rate	$20.59
Rate for Payer: AlohaCare Medicaid	$10.62
Rate for Payer: AlohaCare Medicare	$8.92
Rate for Payer: Cash Price	$13.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$19.53
Rate for Payer: Devoted Health Medicare	$8.92
Rate for Payer: Hawaii Medical Service Association Medicare	$8.92
Rate for Payer: Hawaii Western Management Group Commercial	$20.17
Rate for Payer: Health Management Network Commercial	$18.05
Rate for Payer: Humana Medicare	$8.92
Rate for Payer: Kaiser Permanente Commercial	$19.11
Rate for Payer: Kaiser Permanente Medicaid	$10.83
Rate for Payer: Kaiser Permanente Medicare	$8.92
Rate for Payer: MDX Hawaii PPO	$20.59
Rate for Payer: Ohana Health Plan Medicaid	$8.92
Rate for Payer: Ohana Health Plan Medicare	$8.92
Rate for Payer: UnitedHealthcare Medicare	$8.92
Rate for Payer: University Health Alliance Commercial	$15.47

apixaban 2.5 mg Tab [KMC]

Facility

$21.23

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$20.59
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$18.05
Rate for Payer: Kaiser Permanente Commercial	$19.11
Rate for Payer: MDX Hawaii PPO	$20.59

apixaban 5 mg Tab [KMC]

Facility

$42.32

Service Code	NDC 00003089431
Hospital Revenue Code	250
Min. Negotiated Rate	$35.97
Max. Negotiated Rate	$41.05
Rate for Payer: Cash Price	$27.51
Rate for Payer: Health Management Network Commercial	$35.97
Rate for Payer: Kaiser Permanente Commercial	$38.09
Rate for Payer: MDX Hawaii PPO	$41.05

apixaban 5 mg Tab [KMC]

Facility

$42.32

Service Code	NDC 00003089431
Hospital Revenue Code	250
Min. Negotiated Rate	$17.77
Max. Negotiated Rate	$41.05
Rate for Payer: AlohaCare Medicaid	$21.16
Rate for Payer: AlohaCare Medicare	$17.77
Rate for Payer: Cash Price	$27.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$38.93
Rate for Payer: Devoted Health Medicare	$17.77
Rate for Payer: Hawaii Medical Service Association Medicare	$17.77
Rate for Payer: Hawaii Western Management Group Commercial	$40.20
Rate for Payer: Health Management Network Commercial	$35.97
Rate for Payer: Humana Medicare	$17.77
Rate for Payer: Kaiser Permanente Commercial	$38.09
Rate for Payer: Kaiser Permanente Medicaid	$21.58
Rate for Payer: Kaiser Permanente Medicare	$17.77
Rate for Payer: MDX Hawaii PPO	$41.05
Rate for Payer: Ohana Health Plan Medicaid	$17.77
Rate for Payer: Ohana Health Plan Medicare	$17.77
Rate for Payer: UnitedHealthcare Medicaid	$25.39
Rate for Payer: UnitedHealthcare Medicare	$17.77
Rate for Payer: University Health Alliance Commercial	$30.85

APPENDIX PROCEDURES WITH CC

Facility

$31,689.57

Service Code	MSDRG 398
Min. Negotiated Rate	$31,689.57
Max. Negotiated Rate	$31,689.57
Rate for Payer: Hawaii Medical Service Association Commercial	$31,689.57

APPENDIX PROCEDURES WITH MCC

Facility

$34,320.50

Service Code	MSDRG 397
Min. Negotiated Rate	$34,320.50
Max. Negotiated Rate	$34,320.50
Rate for Payer: Hawaii Medical Service Association Commercial	$34,320.50

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$23,654.60

Service Code	MSDRG 399
Min. Negotiated Rate	$23,654.60
Max. Negotiated Rate	$23,654.60
Rate for Payer: Hawaii Medical Service Association Commercial	$23,654.60

Know your out-of-pocket cost for care.

All Charges