Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

RV5 VACCINE 3 DOSE SCHEDULE LIVE FOR ORAL USE

Professional

Both

$218.00

Service Code	HCPCS 90680
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$185.30
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Hawaii Western Management Group Commercial	$89.39
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

RV5 VACCINE 3 DOSE SCHEDULE LIVE FOR ORAL USE

Professional

Both

$0.01

Service Code	HCPCS 90680 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$89.39
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	$89.39
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

RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD

Professional

Both

$0.01

Service Code	HCPCS 1160F
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	$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

SACROILIAC JOINTS 3PL VWS

Facility

$369.00

Service Code	HCPCS 72202
Hospital Charge Code	424722020
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$71.43

SACROILIAC JOINTS 3PL VWS

Facility

$369.00

Service Code	HCPCS 72202
Hospital Charge Code	424722020
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

SACROILIAC JOINTS LT 3 VIEWS

Facility

$369.00

Service Code	HCPCS 72200
Hospital Charge Code	424722000
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

SACROILIAC JOINTS LT 3 VIEWS

Facility

$369.00

Service Code	HCPCS 72200
Hospital Charge Code	424722000
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$59.38

SACRUM AND COCCYX MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 72220
Hospital Charge Code	424722200
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

SACRUM AND COCCYX MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 72220
Hospital Charge Code	424722200
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$62.01

sacubitril-valsartan 24 mg-26 mg Tab [KMC]

Facility

$49.90

Service Code	NDC 00078065920
Hospital Revenue Code	250
Min. Negotiated Rate	$20.96
Max. Negotiated Rate	$48.40
Rate for Payer: AlohaCare Medicaid	$24.95
Rate for Payer: AlohaCare Medicare	$20.96
Rate for Payer: Cash Price	$32.44
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$45.91
Rate for Payer: Devoted Health Medicare	$20.96
Rate for Payer: Hawaii Medical Service Association Medicare	$20.96
Rate for Payer: Hawaii Western Management Group Commercial	$47.41
Rate for Payer: Health Management Network Commercial	$42.41
Rate for Payer: Humana Medicare	$20.96
Rate for Payer: Kaiser Permanente Commercial	$44.91
Rate for Payer: Kaiser Permanente Medicaid	$25.45
Rate for Payer: Kaiser Permanente Medicare	$20.96
Rate for Payer: MDX Hawaii PPO	$48.40
Rate for Payer: Ohana Health Plan Medicaid	$20.96
Rate for Payer: Ohana Health Plan Medicare	$20.96
Rate for Payer: UnitedHealthcare Medicaid	$29.94
Rate for Payer: UnitedHealthcare Medicare	$20.96
Rate for Payer: University Health Alliance Commercial	$36.37

sacubitril-valsartan 24 mg-26 mg Tab [KMC]

Facility

$49.90

Service Code	NDC 00078065920
Hospital Revenue Code	250
Min. Negotiated Rate	$42.41
Max. Negotiated Rate	$48.40
Rate for Payer: Cash Price	$32.44
Rate for Payer: Health Management Network Commercial	$42.41
Rate for Payer: Kaiser Permanente Commercial	$44.91
Rate for Payer: MDX Hawaii PPO	$48.40

sacubitril-valsartan 49 mg-51 mg Tab [KMC]

Facility

$49.90

Service Code	NDC 00078077720
Hospital Revenue Code	250
Min. Negotiated Rate	$42.41
Max. Negotiated Rate	$48.40
Rate for Payer: Cash Price	$32.44
Rate for Payer: Health Management Network Commercial	$42.41
Rate for Payer: Kaiser Permanente Commercial	$44.91
Rate for Payer: MDX Hawaii PPO	$48.40

sacubitril-valsartan 49 mg-51 mg Tab [KMC]

Facility

$49.90

Service Code	NDC 00078077720
Hospital Revenue Code	250
Min. Negotiated Rate	$20.96
Max. Negotiated Rate	$48.40
Rate for Payer: AlohaCare Medicaid	$24.95
Rate for Payer: AlohaCare Medicare	$20.96
Rate for Payer: Cash Price	$32.44
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$45.91
Rate for Payer: Devoted Health Medicare	$20.96
Rate for Payer: Hawaii Medical Service Association Medicare	$20.96
Rate for Payer: Hawaii Western Management Group Commercial	$47.41
Rate for Payer: Health Management Network Commercial	$42.41
Rate for Payer: Humana Medicare	$20.96
Rate for Payer: Kaiser Permanente Commercial	$44.91
Rate for Payer: Kaiser Permanente Medicaid	$25.45
Rate for Payer: Kaiser Permanente Medicare	$20.96
Rate for Payer: MDX Hawaii PPO	$48.40
Rate for Payer: Ohana Health Plan Medicaid	$20.96
Rate for Payer: Ohana Health Plan Medicare	$20.96
Rate for Payer: UnitedHealthcare Medicaid	$29.94
Rate for Payer: UnitedHealthcare Medicare	$20.96
Rate for Payer: University Health Alliance Commercial	$36.37

sacubitril-valsartan 97 -103 mg Tab [KMC]

Facility

$40.73

Service Code	NDC 00078069620
Hospital Revenue Code	250
Min. Negotiated Rate	$34.62
Max. Negotiated Rate	$39.51
Rate for Payer: Cash Price	$26.47
Rate for Payer: Health Management Network Commercial	$34.62
Rate for Payer: Kaiser Permanente Commercial	$36.66
Rate for Payer: MDX Hawaii PPO	$39.51

sacubitril-valsartan 97 -103 mg Tab [KMC]

Facility

$40.73

Service Code	NDC 00078069620
Hospital Revenue Code	250
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$39.51
Rate for Payer: AlohaCare Medicaid	$20.36
Rate for Payer: AlohaCare Medicare	$17.11
Rate for Payer: Cash Price	$26.47
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$37.47
Rate for Payer: Devoted Health Medicare	$17.11
Rate for Payer: Hawaii Medical Service Association Medicare	$17.11
Rate for Payer: Hawaii Western Management Group Commercial	$38.69
Rate for Payer: Health Management Network Commercial	$34.62
Rate for Payer: Humana Medicare	$17.11
Rate for Payer: Kaiser Permanente Commercial	$36.66
Rate for Payer: Kaiser Permanente Medicaid	$20.77
Rate for Payer: Kaiser Permanente Medicare	$17.11
Rate for Payer: MDX Hawaii PPO	$39.51
Rate for Payer: Ohana Health Plan Medicaid	$17.11
Rate for Payer: Ohana Health Plan Medicare	$17.11
Rate for Payer: UnitedHealthcare Medicaid	$24.44
Rate for Payer: UnitedHealthcare Medicare	$17.11
Rate for Payer: University Health Alliance Commercial	$29.69

SALEM SUMP 14FR

Facility

$3.00

Hospital Charge Code	8253
Hospital Revenue Code	270
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

SALEM SUMP 14FR

Facility

$3.00

Hospital Charge Code	8253
Hospital Revenue Code	270
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

SALEM SUMP 16FR

Facility

$93.00

Hospital Charge Code	8254
Hospital Revenue Code	270
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$90.21
Rate for Payer: Cash Price	$60.45
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: MDX Hawaii PPO	$90.21

SALEM SUMP 16FR

Facility

$93.00

Hospital Charge Code	8254
Hospital Revenue Code	270
Min. Negotiated Rate	$39.06
Max. Negotiated Rate	$90.21
Rate for Payer: AlohaCare Medicaid	$46.50
Rate for Payer: AlohaCare Medicare	$39.06
Rate for Payer: Cash Price	$60.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$85.56
Rate for Payer: Devoted Health Medicare	$39.06
Rate for Payer: Hawaii Medical Service Association Medicare	$39.06
Rate for Payer: Hawaii Western Management Group Commercial	$88.35
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Humana Medicare	$39.06
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: Kaiser Permanente Medicare	$39.06
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: Ohana Health Plan Medicaid	$39.06
Rate for Payer: Ohana Health Plan Medicare	$39.06
Rate for Payer: UnitedHealthcare Medicare	$39.06
Rate for Payer: University Health Alliance Commercial	$67.79

SALEM SUMP 18FR

Facility

$5.00

Hospital Charge Code	8255
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

SALEM SUMP 18FR

Facility

$5.00

Hospital Charge Code	8255
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

Salicylate DLS

Facility

$192.00

Service Code	HCPCS 80329
Hospital Charge Code	422803295
Hospital Revenue Code	301
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$186.24
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: MDX Hawaii PPO	$186.24

Salicylate DLS

Facility

$192.00

Service Code	HCPCS 80329
Hospital Charge Code	422803295
Hospital Revenue Code	301
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$80.64
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$176.64
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.61
Rate for Payer: Hawaii Medical Service Association Medicare	$80.64
Rate for Payer: Hawaii Western Management Group Commercial	$182.40
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$80.64
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$80.64
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$80.64
Rate for Payer: Ohana Health Plan Medicare	$80.64
Rate for Payer: UnitedHealthcare Medicare	$80.64
Rate for Payer: University Health Alliance Commercial	$139.95

Salicylate Level

Facility

$130.00

Service Code	HCPCS 80329
Hospital Charge Code	422803290
Hospital Revenue Code	301
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$126.10
Rate for Payer: AlohaCare Medicaid	$65.00
Rate for Payer: AlohaCare Medicare	$54.60
Rate for Payer: Cash Price	$84.50
Rate for Payer: Cash Price	$84.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$119.60
Rate for Payer: Devoted Health Medicare	$54.60
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.61
Rate for Payer: Hawaii Medical Service Association Medicare	$54.60
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Humana Medicare	$54.60
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: Kaiser Permanente Medicaid	$66.30
Rate for Payer: Kaiser Permanente Medicare	$54.60
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: Ohana Health Plan Medicaid	$54.60
Rate for Payer: Ohana Health Plan Medicare	$54.60
Rate for Payer: UnitedHealthcare Medicare	$54.60
Rate for Payer: University Health Alliance Commercial	$94.76

Salicylate Level

Facility

$130.00

Service Code	HCPCS 80329
Hospital Charge Code	422803290
Hospital Revenue Code	301
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$84.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: MDX Hawaii PPO	$126.10

Know your out-of-pocket cost for care.

All Charges