Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

PSA, Total, Screen DLS

Facility

$114.00

Service Code	HCPCS G0103
Hospital Charge Code	422G01035
Hospital Revenue Code	301
Min. Negotiated Rate	$24.14
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$47.88
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$104.88
Rate for Payer: Devoted Health Medicare	$47.88
Rate for Payer: Hawaii Medical Service Association Commercial	$24.14
Rate for Payer: Hawaii Medical Service Association Medicare	$47.88
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$47.88
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$47.88
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$47.88
Rate for Payer: Ohana Health Plan Medicare	$47.88
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$47.88
Rate for Payer: University Health Alliance Commercial	$83.09

pseudoephedrine 120 mg ER Tab [KMC]

Facility

$3.00

Service Code	NDC 00904675415
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

pseudoephedrine 120 mg ER Tab [KMC]

Facility

$3.00

Service Code	NDC 00904675415
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

pseudoephedrine 30 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904505324
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

pseudoephedrine 30 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904505324
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

PSYCHIATRIC DIAGNOSTIC EVALUATION

Professional

Both

$552.00

Service Code	HCPCS 90791 CG
Hospital Revenue Code	900
Min. Negotiated Rate	$138.14
Max. Negotiated Rate	$469.20
Rate for Payer: AlohaCare Medicaid	$148.43
Rate for Payer: Cash Price	$358.80
Rate for Payer: Cash Price	$358.80
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$148.43
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Ohana Health Plan Medicaid	$148.43
Rate for Payer: UnitedHealthcare Medicaid	$148.43
Rate for Payer: University Health Alliance Commercial	$179.86

PSYCHIATRIC DIAGNOSTIC EVALUATION

Professional

Both

$552.00

Service Code	HCPCS 90791
Hospital Revenue Code	900
Min. Negotiated Rate	$138.14
Max. Negotiated Rate	$469.20
Rate for Payer: AlohaCare Medicaid	$148.43
Rate for Payer: AlohaCare Medicare	$138.14
Rate for Payer: Cash Price	$358.80
Rate for Payer: Cash Price	$358.80
Rate for Payer: Devoted Health Medicare	$138.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$148.43
Rate for Payer: Hawaii Medical Service Association Medicare	$138.14
Rate for Payer: Health Management Network Commercial	$469.20
Rate for Payer: Kaiser Permanente Commercial	$165.77
Rate for Payer: Kaiser Permanente Medicaid	$165.77
Rate for Payer: Kaiser Permanente Medicare	$165.77
Rate for Payer: Ohana Health Plan Medicaid	$148.43
Rate for Payer: Ohana Health Plan Medicare	$138.14
Rate for Payer: UnitedHealthcare Medicaid	$148.43
Rate for Payer: UnitedHealthcare Medicare	$138.14
Rate for Payer: University Health Alliance Commercial	$179.86

PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES

Professional

Both

$596.00

Service Code	HCPCS 90792 CG
Hospital Revenue Code	900
Min. Negotiated Rate	$158.95
Max. Negotiated Rate	$506.60
Rate for Payer: AlohaCare Medicaid	$170.34
Rate for Payer: Cash Price	$387.40
Rate for Payer: Cash Price	$387.40
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$170.34
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: Ohana Health Plan Medicaid	$170.34
Rate for Payer: UnitedHealthcare Medicaid	$170.34
Rate for Payer: University Health Alliance Commercial	$205.90

PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES

Professional

Both

$596.00

Service Code	HCPCS 90792
Hospital Revenue Code	900
Min. Negotiated Rate	$158.95
Max. Negotiated Rate	$506.60
Rate for Payer: AlohaCare Medicaid	$170.34
Rate for Payer: AlohaCare Medicare	$158.95
Rate for Payer: Cash Price	$387.40
Rate for Payer: Cash Price	$387.40
Rate for Payer: Devoted Health Medicare	$158.95
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$170.34
Rate for Payer: Hawaii Medical Service Association Medicare	$158.95
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: Kaiser Permanente Commercial	$190.74
Rate for Payer: Kaiser Permanente Medicaid	$190.74
Rate for Payer: Kaiser Permanente Medicare	$190.74
Rate for Payer: Ohana Health Plan Medicaid	$170.34
Rate for Payer: Ohana Health Plan Medicare	$158.95
Rate for Payer: UnitedHealthcare Medicaid	$170.34
Rate for Payer: UnitedHealthcare Medicare	$158.95
Rate for Payer: University Health Alliance Commercial	$205.90

PSYCHOANALYSIS

Professional

Both

$324.00

Service Code	HCPCS 90845 CG
Hospital Revenue Code	900
Min. Negotiated Rate	$87.16
Max. Negotiated Rate	$275.40
Rate for Payer: AlohaCare Medicaid	$87.16
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$87.16
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Ohana Health Plan Medicaid	$87.16
Rate for Payer: UnitedHealthcare Medicaid	$87.16
Rate for Payer: University Health Alliance Commercial	$100.92

PSYCHOANALYSIS

Professional

Both

$324.00

Service Code	HCPCS 90845
Hospital Revenue Code	900
Min. Negotiated Rate	$87.16
Max. Negotiated Rate	$275.40
Rate for Payer: AlohaCare Medicaid	$87.16
Rate for Payer: AlohaCare Medicare	$88.53
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$88.53
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$87.16
Rate for Payer: Hawaii Medical Service Association Medicare	$88.53
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$106.24
Rate for Payer: Kaiser Permanente Medicaid	$106.24
Rate for Payer: Kaiser Permanente Medicare	$106.24
Rate for Payer: Ohana Health Plan Medicaid	$87.16
Rate for Payer: Ohana Health Plan Medicare	$88.53
Rate for Payer: UnitedHealthcare Medicaid	$87.16
Rate for Payer: UnitedHealthcare Medicare	$88.53
Rate for Payer: University Health Alliance Commercial	$100.92

PSYCHOSES

Facility

$15,761.83

Service Code	MSDRG 885
Min. Negotiated Rate	$15,761.83
Max. Negotiated Rate	$15,761.83
Rate for Payer: Hawaii Medical Service Association Commercial	$15,761.83

PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES

Professional

Both

$485.00

Service Code	HCPCS 90839 CG
Hospital Revenue Code	900
Min. Negotiated Rate	$129.79
Max. Negotiated Rate	$412.25
Rate for Payer: AlohaCare Medicaid	$129.79
Rate for Payer: Cash Price	$315.25
Rate for Payer: Cash Price	$315.25
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$129.79
Rate for Payer: Health Management Network Commercial	$412.25
Rate for Payer: Ohana Health Plan Medicaid	$129.79
Rate for Payer: UnitedHealthcare Medicaid	$129.79
Rate for Payer: University Health Alliance Commercial	$149.05

PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES

Professional

Both

$485.00

Service Code	HCPCS 90839
Hospital Revenue Code	900
Min. Negotiated Rate	$129.79
Max. Negotiated Rate	$412.25
Rate for Payer: AlohaCare Medicaid	$129.79
Rate for Payer: AlohaCare Medicare	$130.41
Rate for Payer: Cash Price	$315.25
Rate for Payer: Cash Price	$315.25
Rate for Payer: Devoted Health Medicare	$130.41
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$129.79
Rate for Payer: Hawaii Medical Service Association Medicare	$130.41
Rate for Payer: Health Management Network Commercial	$412.25
Rate for Payer: Kaiser Permanente Commercial	$156.49
Rate for Payer: Kaiser Permanente Medicaid	$156.49
Rate for Payer: Kaiser Permanente Medicare	$156.49
Rate for Payer: Ohana Health Plan Medicaid	$129.79
Rate for Payer: Ohana Health Plan Medicare	$130.41
Rate for Payer: UnitedHealthcare Medicaid	$129.79
Rate for Payer: UnitedHealthcare Medicare	$130.41
Rate for Payer: University Health Alliance Commercial	$149.05

PSYCHOTHERAPY W/PATIENT 30 MINUTES

Professional

Both

$258.00

Service Code	HCPCS 90832
Hospital Revenue Code	900
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$219.30
Rate for Payer: AlohaCare Medicaid	$68.60
Rate for Payer: AlohaCare Medicare	$69.93
Rate for Payer: Cash Price	$167.70
Rate for Payer: Cash Price	$167.70
Rate for Payer: Devoted Health Medicare	$69.93
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$68.60
Rate for Payer: Hawaii Medical Service Association Medicare	$69.93
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Kaiser Permanente Commercial	$83.92
Rate for Payer: Kaiser Permanente Medicaid	$83.92
Rate for Payer: Kaiser Permanente Medicare	$83.92
Rate for Payer: Ohana Health Plan Medicaid	$68.60
Rate for Payer: Ohana Health Plan Medicare	$69.93
Rate for Payer: UnitedHealthcare Medicaid	$68.60
Rate for Payer: UnitedHealthcare Medicare	$69.93
Rate for Payer: University Health Alliance Commercial	$80.22

PSYCHOTHERAPY W/PATIENT 30 MINUTES

Professional

Both

$258.00

Service Code	HCPCS 90832 CG
Hospital Revenue Code	900
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$219.30
Rate for Payer: AlohaCare Medicaid	$68.60
Rate for Payer: Cash Price	$167.70
Rate for Payer: Cash Price	$167.70
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$68.60
Rate for Payer: Health Management Network Commercial	$219.30
Rate for Payer: Ohana Health Plan Medicaid	$68.60
Rate for Payer: UnitedHealthcare Medicaid	$68.60
Rate for Payer: University Health Alliance Commercial	$80.22

PSYCHOTHERAPY W/PATIENT 45 MINUTES

Professional

Both

$338.00

Service Code	HCPCS 90834 CG
Hospital Revenue Code	900
Min. Negotiated Rate	$90.82
Max. Negotiated Rate	$287.30
Rate for Payer: AlohaCare Medicaid	$90.82
Rate for Payer: Cash Price	$219.70
Rate for Payer: Cash Price	$219.70
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$90.82
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: Ohana Health Plan Medicaid	$90.82
Rate for Payer: UnitedHealthcare Medicaid	$90.82
Rate for Payer: University Health Alliance Commercial	$105.43

PSYCHOTHERAPY W/PATIENT 45 MINUTES

Professional

Both

$338.00

Service Code	HCPCS 90834
Hospital Revenue Code	900
Min. Negotiated Rate	$90.82
Max. Negotiated Rate	$287.30
Rate for Payer: AlohaCare Medicaid	$90.82
Rate for Payer: AlohaCare Medicare	$92.35
Rate for Payer: Cash Price	$219.70
Rate for Payer: Cash Price	$219.70
Rate for Payer: Devoted Health Medicare	$92.35
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$90.82
Rate for Payer: Hawaii Medical Service Association Medicare	$92.35
Rate for Payer: Health Management Network Commercial	$287.30
Rate for Payer: Kaiser Permanente Commercial	$110.82
Rate for Payer: Kaiser Permanente Medicaid	$110.82
Rate for Payer: Kaiser Permanente Medicare	$110.82
Rate for Payer: Ohana Health Plan Medicaid	$90.82
Rate for Payer: Ohana Health Plan Medicare	$92.35
Rate for Payer: UnitedHealthcare Medicaid	$90.82
Rate for Payer: UnitedHealthcare Medicare	$92.35
Rate for Payer: University Health Alliance Commercial	$105.43

PSYCHOTHERAPY W/PATIENT 60 MINUTES

Professional

Both

$499.00

Service Code	HCPCS 90837
Hospital Revenue Code	900
Min. Negotiated Rate	$134.02
Max. Negotiated Rate	$424.15
Rate for Payer: AlohaCare Medicaid	$134.02
Rate for Payer: AlohaCare Medicare	$136.14
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Devoted Health Medicare	$136.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$134.02
Rate for Payer: Hawaii Medical Service Association Medicare	$136.14
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Kaiser Permanente Commercial	$163.37
Rate for Payer: Kaiser Permanente Medicaid	$163.37
Rate for Payer: Kaiser Permanente Medicare	$163.37
Rate for Payer: Ohana Health Plan Medicaid	$134.02
Rate for Payer: Ohana Health Plan Medicare	$136.14
Rate for Payer: UnitedHealthcare Medicaid	$134.02
Rate for Payer: UnitedHealthcare Medicare	$136.14
Rate for Payer: University Health Alliance Commercial	$155.93

PSYCHOTHERAPY W/PATIENT 60 MINUTES

Professional

Both

$499.00

Service Code	HCPCS 90837 CG
Hospital Revenue Code	900
Min. Negotiated Rate	$134.02
Max. Negotiated Rate	$424.15
Rate for Payer: AlohaCare Medicaid	$134.02
Rate for Payer: Cash Price	$324.35
Rate for Payer: Cash Price	$324.35
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$134.02
Rate for Payer: Health Management Network Commercial	$424.15
Rate for Payer: Ohana Health Plan Medicaid	$134.02
Rate for Payer: UnitedHealthcare Medicaid	$134.02
Rate for Payer: University Health Alliance Commercial	$155.93

Psyllium 5.8 g Powder [KMC]

Facility

$0.09

Service Code	NDC 37000074084
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.09
Rate for Payer: AlohaCare Medicaid	$0.05
Rate for Payer: AlohaCare Medicare	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.08
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$0.09
Rate for Payer: Health Management Network Commercial	$0.08
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.08
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.09
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.05
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

Psyllium 5.8 g Powder [KMC]

Facility

$0.09

Service Code	NDC 37000074084
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.08
Rate for Payer: Kaiser Permanente Commercial	$0.08
Rate for Payer: MDX Hawaii PPO	$0.09

PT Cognitive Function Medicare Charge

Facility

$161.00

Service Code	HCPCS G0515 GP
Hospital Charge Code	432G05150
Hospital Revenue Code	432
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$104.65
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: MDX Hawaii PPO	$156.17

PT Cognitive Function Medicare Charge

Facility

$161.00

Service Code	HCPCS G0515 GP
Hospital Charge Code	432G05150
Hospital Revenue Code	432
Min. Negotiated Rate	$67.62
Max. Negotiated Rate	$156.17
Rate for Payer: AlohaCare Medicaid	$80.50
Rate for Payer: AlohaCare Medicare	$67.62
Rate for Payer: Cash Price	$104.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$148.12
Rate for Payer: Devoted Health Medicare	$67.62
Rate for Payer: Hawaii Medical Service Association Medicare	$67.62
Rate for Payer: Hawaii Western Management Group Commercial	$152.95
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Humana Medicare	$67.62
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$82.11
Rate for Payer: Kaiser Permanente Medicare	$67.62
Rate for Payer: MDX Hawaii PPO	$156.17
Rate for Payer: Ohana Health Plan Medicaid	$67.62
Rate for Payer: Ohana Health Plan Medicare	$67.62
Rate for Payer: UnitedHealthcare Medicare	$67.62
Rate for Payer: University Health Alliance Commercial	$117.35

PT Community/Work Reintegration Charge

Facility

$179.00

Service Code	HCPCS 97537 GP
Hospital Charge Code	432975370
Hospital Revenue Code	421
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

Know your out-of-pocket cost for care.

All Charges