Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

PROSTHETIC TRAIN EA 15MIN Occupational

Facility

$179.00

Service Code	HCPCS 97761 GO
Hospital Charge Code	426977610
Hospital Revenue Code	431
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

PROSTHETIC TRAIN EA 15MIN Occupational

Facility

$179.00

Service Code	HCPCS 97761 GO
Hospital Charge Code	426977610
Hospital Revenue Code	431
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$17.70
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

PROSTHETIC TRAIN EA 15MIN Physical

Facility

$179.00

Service Code	HCPCS 97761 GP
Hospital Charge Code	432977610
Hospital Revenue Code	420
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

PROSTHETIC TRAIN EA 15MIN Physical

Facility

$179.00

Service Code	HCPCS 97761 GP
Hospital Charge Code	432977610
Hospital Revenue Code	420
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$17.70
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

Prosthetic Training Charges

Facility

$179.00

Service Code	HCPCS 97761 GP
Hospital Charge Code	432977610
Hospital Revenue Code	420
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

Prosthetic Training Charges

Facility

$179.00

Service Code	HCPCS 97761 GP
Hospital Charge Code	432977610
Hospital Revenue Code	420
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$17.70
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

Protein, 24 Hr Urine DLS

Facility

$185.00

Service Code	HCPCS 84156
Hospital Charge Code	422841565
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: MDX Hawaii PPO	$179.45

Protein, 24 Hr Urine DLS

Facility

$185.00

Service Code	HCPCS 84156
Hospital Charge Code	422841565
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$92.50
Rate for Payer: AlohaCare Medicare	$77.70
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$170.20
Rate for Payer: Devoted Health Medicare	$77.70
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$77.70
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$77.70
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$77.70
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$77.70
Rate for Payer: Ohana Health Plan Medicare	$77.70
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$77.70
Rate for Payer: University Health Alliance Commercial	$9.47

Protein C Activity DLS

Facility

$251.00

Service Code	HCPCS 85303
Hospital Charge Code	422853035
Hospital Revenue Code	305
Min. Negotiated Rate	$13.84
Max. Negotiated Rate	$243.47
Rate for Payer: AlohaCare Medicaid	$125.50
Rate for Payer: AlohaCare Medicare	$105.42
Rate for Payer: Cash Price	$163.15
Rate for Payer: Cash Price	$163.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$230.92
Rate for Payer: Devoted Health Medicare	$105.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.11
Rate for Payer: Hawaii Medical Service Association Commercial	$17.30
Rate for Payer: Hawaii Medical Service Association Medicare	$105.42
Rate for Payer: Hawaii Western Management Group Commercial	$13.84
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Humana Medicare	$105.42
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: Kaiser Permanente Medicaid	$128.01
Rate for Payer: Kaiser Permanente Medicare	$105.42
Rate for Payer: MDX Hawaii PPO	$243.47
Rate for Payer: Ohana Health Plan Medicaid	$105.42
Rate for Payer: Ohana Health Plan Medicare	$105.42
Rate for Payer: UnitedHealthcare Medicaid	$19.11
Rate for Payer: UnitedHealthcare Medicare	$105.42
Rate for Payer: University Health Alliance Commercial	$35.74

Protein C Activity DLS

Facility

$251.00

Service Code	HCPCS 85303
Hospital Charge Code	422853035
Hospital Revenue Code	305
Min. Negotiated Rate	$213.35
Max. Negotiated Rate	$243.47
Rate for Payer: Cash Price	$163.15
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: MDX Hawaii PPO	$243.47

Protein-ex 18g/30mL liquid [KMC]

Facility

$6.00

Service Code	NDC 5485953030
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

Protein-ex 18g/30mL liquid [KMC]

Facility

$6.00

Service Code	NDC 5485953030
Hospital Revenue Code	250
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicaid	$3.60
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

Protein, Random Urine DLS

Facility

$37.00

Service Code	HCPCS 84156
Hospital Charge Code	422841565
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$15.54
Rate for Payer: Cash Price	$24.05
Rate for Payer: Cash Price	$24.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.04
Rate for Payer: Devoted Health Medicare	$15.54
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$15.54
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$15.54
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$15.54
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$15.54
Rate for Payer: Ohana Health Plan Medicare	$15.54
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$15.54
Rate for Payer: University Health Alliance Commercial	$9.47

Protein, Random Urine DLS

Facility

$37.00

Service Code	HCPCS 84156
Hospital Charge Code	422841565
Hospital Revenue Code	301
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

Protein S Activity DLS

Facility

$357.00

Service Code	HCPCS 85305
Hospital Charge Code	422853055
Hospital Revenue Code	305
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$346.29
Rate for Payer: AlohaCare Medicaid	$178.50
Rate for Payer: AlohaCare Medicare	$149.94
Rate for Payer: Cash Price	$232.05
Rate for Payer: Cash Price	$232.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$328.44
Rate for Payer: Devoted Health Medicare	$149.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.02
Rate for Payer: Hawaii Medical Service Association Commercial	$14.51
Rate for Payer: Hawaii Medical Service Association Medicare	$149.94
Rate for Payer: Hawaii Western Management Group Commercial	$11.61
Rate for Payer: Health Management Network Commercial	$303.45
Rate for Payer: Humana Medicare	$149.94
Rate for Payer: Kaiser Permanente Commercial	$321.30
Rate for Payer: Kaiser Permanente Medicaid	$182.07
Rate for Payer: Kaiser Permanente Medicare	$149.94
Rate for Payer: MDX Hawaii PPO	$346.29
Rate for Payer: Ohana Health Plan Medicaid	$149.94
Rate for Payer: Ohana Health Plan Medicare	$149.94
Rate for Payer: UnitedHealthcare Medicaid	$16.02
Rate for Payer: UnitedHealthcare Medicare	$149.94
Rate for Payer: University Health Alliance Commercial	$29.97

Protein S Activity DLS

Facility

$357.00

Service Code	HCPCS 85305
Hospital Charge Code	422853055
Hospital Revenue Code	305
Min. Negotiated Rate	$303.45
Max. Negotiated Rate	$346.29
Rate for Payer: Cash Price	$232.05
Rate for Payer: Health Management Network Commercial	$303.45
Rate for Payer: Kaiser Permanente Commercial	$321.30
Rate for Payer: MDX Hawaii PPO	$346.29

Protein Total

Facility

$69.00

Service Code	HCPCS 84155
Hospital Charge Code	422841550
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$5.06
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$5.06
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$9.47

Protein Total

Facility

$69.00

Service Code	HCPCS 84155
Hospital Charge Code	422841550
Hospital Revenue Code	301
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

PROTHROMBIN TIME

Professional

Both

$16.00

Service Code	HCPCS 85610
Hospital Revenue Code	300
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$13.60
Rate for Payer: AlohaCare Medicaid	$5.43
Rate for Payer: AlohaCare Medicare	$4.29
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cash Price	$10.40
Rate for Payer: Devoted Health Medicare	$4.29
Rate for Payer: Hawaii Medical Service Association Medicare	$4.29
Rate for Payer: Hawaii Western Management Group Commercial	$5.43
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$5.15
Rate for Payer: Kaiser Permanente Medicaid	$5.15
Rate for Payer: Kaiser Permanente Medicare	$5.15
Rate for Payer: Ohana Health Plan Medicaid	$5.43
Rate for Payer: Ohana Health Plan Medicare	$4.29
Rate for Payer: UnitedHealthcare Medicaid	$5.43
Rate for Payer: UnitedHealthcare Medicare	$4.29

Prothrombin Time (PT) DLS

Facility

$36.00

Service Code	HCPCS 85730
Hospital Charge Code	422857305
Hospital Revenue Code	305
Min. Negotiated Rate	$6.01
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$15.12
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.12
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.30
Rate for Payer: Hawaii Medical Service Association Commercial	$7.51
Rate for Payer: Hawaii Medical Service Association Medicare	$15.12
Rate for Payer: Hawaii Western Management Group Commercial	$6.01
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$15.12
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$15.12
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$15.12
Rate for Payer: Ohana Health Plan Medicare	$15.12
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: UnitedHealthcare Medicare	$15.12
Rate for Payer: University Health Alliance Commercial	$15.50

Prothrombin Time (PT) DLS

Facility

$36.00

Service Code	HCPCS 85730
Hospital Charge Code	422857305
Hospital Revenue Code	305
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

PRP TREATMENT

Professional

Both

$221.00

Service Code	HCPCS HX0126
Hospital Revenue Code	361
Min. Negotiated Rate	$187.85
Max. Negotiated Rate	$187.85
Rate for Payer: Cash Price	$143.65
Rate for Payer: Health Management Network Commercial	$187.85

PSA, Total, Diagnostic DLS

Facility

$84.00

Service Code	HCPCS 84153
Hospital Charge Code	422841535
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$35.28
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$77.28
Rate for Payer: Devoted Health Medicare	$35.28
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.42
Rate for Payer: Hawaii Medical Service Association Commercial	$22.99
Rate for Payer: Hawaii Medical Service Association Medicare	$35.28
Rate for Payer: Hawaii Western Management Group Commercial	$18.39
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$35.28
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$35.28
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$35.28
Rate for Payer: Ohana Health Plan Medicare	$35.28
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$35.28
Rate for Payer: University Health Alliance Commercial	$47.55

PSA, Total, Diagnostic DLS

Facility

$84.00

Service Code	HCPCS 84153
Hospital Charge Code	422841535
Hospital Revenue Code	301
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

PSA, Total, Screen DLS

Facility

$114.00

Service Code	HCPCS G0103
Hospital Charge Code	422G01035
Hospital Revenue Code	301
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

Know your out-of-pocket cost for care.

All Charges