Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

APPLY LONG ARM SPLINT CHARGE

Facility

$513.00

Service Code	HCPCS 29105
Hospital Charge Code	440291050
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

APPLY LONG LEG SPLINT (KNEE) CHARGE

Facility

$513.00

Service Code	HCPCS 29505
Hospital Charge Code	440295050
Hospital Revenue Code	450
Min. Negotiated Rate	$215.46
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$256.50
Rate for Payer: AlohaCare Medicare	$215.46
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$471.96
Rate for Payer: Devoted Health Medicare	$215.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$215.46
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$215.46
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.46
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$215.46
Rate for Payer: Ohana Health Plan Medicare	$215.46
Rate for Payer: UnitedHealthcare Medicare	$215.46
Rate for Payer: University Health Alliance Commercial	$373.93

APPLY LONG LEG SPLINT (KNEE) CHARGE

Facility

$513.00

Service Code	HCPCS 29505
Hospital Charge Code	440295050
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

APPLY NASAL PACK &/OR CAUTERY CHARGE

Facility

$432.00

Service Code	HCPCS 30901
Hospital Charge Code	440309010
Hospital Revenue Code	450
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: MDX Hawaii PPO	$419.04

APPLY NASAL PACK &/OR CAUTERY CHARGE

Facility

$432.00

Service Code	HCPCS 30901
Hospital Charge Code	440309010
Hospital Revenue Code	450
Min. Negotiated Rate	$181.44
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$216.00
Rate for Payer: AlohaCare Medicare	$181.44
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$397.44
Rate for Payer: Devoted Health Medicare	$181.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$181.44
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Humana Medicare	$181.44
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$181.44
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: Ohana Health Plan Medicaid	$181.44
Rate for Payer: Ohana Health Plan Medicare	$181.44
Rate for Payer: UnitedHealthcare Medicare	$181.44
Rate for Payer: University Health Alliance Commercial	$314.88

APPLY SHORT ARM SPLINT CHARGE

Facility

$513.00

Service Code	HCPCS 29125
Hospital Charge Code	440291250
Hospital Revenue Code	450
Min. Negotiated Rate	$215.46
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$256.50
Rate for Payer: AlohaCare Medicare	$215.46
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$471.96
Rate for Payer: Devoted Health Medicare	$215.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$215.46
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$215.46
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.46
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$215.46
Rate for Payer: Ohana Health Plan Medicare	$215.46
Rate for Payer: UnitedHealthcare Medicare	$215.46
Rate for Payer: University Health Alliance Commercial	$373.93

APPLY SHORT ARM SPLINT CHARGE

Facility

$513.00

Service Code	HCPCS 29125
Hospital Charge Code	440291250
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

APPLY SHORT LEG CAST CHARGE

Facility

$708.00

Service Code	HCPCS 29405
Hospital Charge Code	440294050
Hospital Revenue Code	450
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

APPLY SHORT LEG CAST CHARGE

Facility

$708.00

Service Code	HCPCS 29405
Hospital Charge Code	440294050
Hospital Revenue Code	450
Min. Negotiated Rate	$297.36
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$297.36
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$651.36
Rate for Payer: Devoted Health Medicare	$297.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$297.36
Rate for Payer: Hawaii Western Management Group Commercial	$672.60
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$297.36
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$297.36
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$297.36
Rate for Payer: Ohana Health Plan Medicare	$297.36
Rate for Payer: UnitedHealthcare Medicare	$297.36
Rate for Payer: University Health Alliance Commercial	$516.06

APPLY SHORT LEG SPLINT CHARGE

Facility

$513.00

Service Code	HCPCS 29515
Hospital Charge Code	440295150
Hospital Revenue Code	450
Min. Negotiated Rate	$215.46
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$256.50
Rate for Payer: AlohaCare Medicare	$215.46
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$471.96
Rate for Payer: Devoted Health Medicare	$215.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$215.46
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$215.46
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.46
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$215.46
Rate for Payer: Ohana Health Plan Medicare	$215.46
Rate for Payer: UnitedHealthcare Medicare	$215.46
Rate for Payer: University Health Alliance Commercial	$373.93

APPLY SHORT LEG SPLINT CHARGE

Facility

$513.00

Service Code	HCPCS 29515
Hospital Charge Code	440295150
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

AQUACEL EXTRA 4X5

Facility

$31.00

Hospital Charge Code	8422
Hospital Revenue Code	270
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$20.15
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07

AQUACEL EXTRA 4X5

Facility

$31.00

Hospital Charge Code	8422
Hospital Revenue Code	270
Min. Negotiated Rate	$13.02
Max. Negotiated Rate	$30.07
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicare	$13.02
Rate for Payer: Cash Price	$20.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$28.52
Rate for Payer: Devoted Health Medicare	$13.02
Rate for Payer: Hawaii Medical Service Association Medicare	$13.02
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$13.02
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicare	$13.02
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: Ohana Health Plan Medicaid	$13.02
Rate for Payer: Ohana Health Plan Medicare	$13.02
Rate for Payer: UnitedHealthcare Medicare	$13.02
Rate for Payer: University Health Alliance Commercial	$22.60

ARESOL MASK PEDS

Facility

$4.00

Hospital Charge Code	8025
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

ARESOL MASK PEDS

Facility

$4.00

Hospital Charge Code	8025
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

arformoterol 15 mcg/2 mL Soln [KMC]

Facility

$37.10

Service Code	HCPCS J7605
Hospital Revenue Code	636
Min. Negotiated Rate	$31.54
Max. Negotiated Rate	$35.99
Rate for Payer: Cash Price	$24.12
Rate for Payer: Health Management Network Commercial	$31.54
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: MDX Hawaii PPO	$35.99

arformoterol 15 mcg/2 mL Soln [KMC]

Facility

$37.10

Service Code	HCPCS J7605
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$35.99
Rate for Payer: AlohaCare Medicaid	$18.55
Rate for Payer: AlohaCare Medicare	$15.58
Rate for Payer: Cash Price	$24.12
Rate for Payer: Cash Price	$24.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.13
Rate for Payer: Devoted Health Medicare	$15.58
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.79
Rate for Payer: Hawaii Medical Service Association Medicare	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$35.24
Rate for Payer: Health Management Network Commercial	$31.54
Rate for Payer: Humana Medicare	$15.58
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: Kaiser Permanente Medicaid	$18.92
Rate for Payer: Kaiser Permanente Medicare	$15.58
Rate for Payer: MDX Hawaii PPO	$35.99
Rate for Payer: Ohana Health Plan Medicaid	$15.58
Rate for Payer: Ohana Health Plan Medicare	$15.58
Rate for Payer: UnitedHealthcare Medicaid	$22.26
Rate for Payer: UnitedHealthcare Medicare	$15.58
Rate for Payer: University Health Alliance Commercial	$27.04

ARIPiprazole 10 mg Tab [KMC]

Facility

$127.49

Service Code	NDC 16714014301
Hospital Revenue Code	250
Min. Negotiated Rate	$108.37
Max. Negotiated Rate	$123.67
Rate for Payer: Cash Price	$82.87
Rate for Payer: Health Management Network Commercial	$108.37
Rate for Payer: Kaiser Permanente Commercial	$114.74
Rate for Payer: MDX Hawaii PPO	$123.67

ARIPiprazole 10 mg Tab [KMC]

Facility

$127.49

Service Code	NDC 16714014301
Hospital Revenue Code	250
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$123.67
Rate for Payer: AlohaCare Medicaid	$63.74
Rate for Payer: AlohaCare Medicare	$53.55
Rate for Payer: Cash Price	$82.87
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$117.29
Rate for Payer: Devoted Health Medicare	$53.55
Rate for Payer: Hawaii Medical Service Association Medicare	$53.55
Rate for Payer: Hawaii Western Management Group Commercial	$121.12
Rate for Payer: Health Management Network Commercial	$108.37
Rate for Payer: Humana Medicare	$53.55
Rate for Payer: Kaiser Permanente Commercial	$114.74
Rate for Payer: Kaiser Permanente Medicaid	$65.02
Rate for Payer: Kaiser Permanente Medicare	$53.55
Rate for Payer: MDX Hawaii PPO	$123.67
Rate for Payer: Ohana Health Plan Medicaid	$53.55
Rate for Payer: Ohana Health Plan Medicare	$53.55
Rate for Payer: UnitedHealthcare Medicaid	$76.49
Rate for Payer: UnitedHealthcare Medicare	$53.55
Rate for Payer: University Health Alliance Commercial	$92.93

ARIPiprazole 15 mg Tab [KMC]

Facility

$127.65

Service Code	NDC 16714014401
Hospital Revenue Code	250
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$123.82
Rate for Payer: Cash Price	$82.97
Rate for Payer: Health Management Network Commercial	$108.50
Rate for Payer: Kaiser Permanente Commercial	$114.89
Rate for Payer: MDX Hawaii PPO	$123.82

ARIPiprazole 15 mg Tab [KMC]

Facility

$127.65

Service Code	NDC 16714014401
Hospital Revenue Code	250
Min. Negotiated Rate	$53.61
Max. Negotiated Rate	$123.82
Rate for Payer: AlohaCare Medicaid	$63.83
Rate for Payer: AlohaCare Medicare	$53.61
Rate for Payer: Cash Price	$82.97
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$117.44
Rate for Payer: Devoted Health Medicare	$53.61
Rate for Payer: Hawaii Medical Service Association Medicare	$53.61
Rate for Payer: Hawaii Western Management Group Commercial	$121.27
Rate for Payer: Health Management Network Commercial	$108.50
Rate for Payer: Humana Medicare	$53.61
Rate for Payer: Kaiser Permanente Commercial	$114.89
Rate for Payer: Kaiser Permanente Medicaid	$65.10
Rate for Payer: Kaiser Permanente Medicare	$53.61
Rate for Payer: MDX Hawaii PPO	$123.82
Rate for Payer: Ohana Health Plan Medicaid	$53.61
Rate for Payer: Ohana Health Plan Medicare	$53.61
Rate for Payer: UnitedHealthcare Medicaid	$76.59
Rate for Payer: UnitedHealthcare Medicare	$53.61
Rate for Payer: University Health Alliance Commercial	$93.04

ARIPiprazole 20 mg Tab [KMC]

Facility

$126.32

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$53.05
Max. Negotiated Rate	$122.53
Rate for Payer: AlohaCare Medicaid	$63.16
Rate for Payer: AlohaCare Medicare	$53.05
Rate for Payer: Cash Price	$82.11
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$116.21
Rate for Payer: Devoted Health Medicare	$53.05
Rate for Payer: Hawaii Medical Service Association Medicare	$53.05
Rate for Payer: Hawaii Western Management Group Commercial	$120.00
Rate for Payer: Health Management Network Commercial	$107.37
Rate for Payer: Humana Medicare	$53.05
Rate for Payer: Kaiser Permanente Commercial	$113.69
Rate for Payer: Kaiser Permanente Medicaid	$64.42
Rate for Payer: Kaiser Permanente Medicare	$53.05
Rate for Payer: MDX Hawaii PPO	$122.53
Rate for Payer: Ohana Health Plan Medicaid	$53.05
Rate for Payer: Ohana Health Plan Medicare	$53.05
Rate for Payer: UnitedHealthcare Medicare	$53.05
Rate for Payer: University Health Alliance Commercial	$92.07

ARIPiprazole 20 mg Tab [KMC]

Facility

$126.32

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$107.37
Max. Negotiated Rate	$122.53
Rate for Payer: Cash Price	$82.11
Rate for Payer: Health Management Network Commercial	$107.37
Rate for Payer: Kaiser Permanente Commercial	$113.69
Rate for Payer: MDX Hawaii PPO	$122.53

ARIPiprazole 2 mg Tab [KMC]

Facility

$126.92

Service Code	NDC 16714078301
Hospital Revenue Code	250
Min. Negotiated Rate	$53.31
Max. Negotiated Rate	$123.11
Rate for Payer: AlohaCare Medicaid	$63.46
Rate for Payer: AlohaCare Medicare	$53.31
Rate for Payer: Cash Price	$82.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$116.77
Rate for Payer: Devoted Health Medicare	$53.31
Rate for Payer: Hawaii Medical Service Association Medicare	$53.31
Rate for Payer: Hawaii Western Management Group Commercial	$120.57
Rate for Payer: Health Management Network Commercial	$107.88
Rate for Payer: Humana Medicare	$53.31
Rate for Payer: Kaiser Permanente Commercial	$114.23
Rate for Payer: Kaiser Permanente Medicaid	$64.73
Rate for Payer: Kaiser Permanente Medicare	$53.31
Rate for Payer: MDX Hawaii PPO	$123.11
Rate for Payer: Ohana Health Plan Medicaid	$53.31
Rate for Payer: Ohana Health Plan Medicare	$53.31
Rate for Payer: UnitedHealthcare Medicaid	$76.15
Rate for Payer: UnitedHealthcare Medicare	$53.31
Rate for Payer: University Health Alliance Commercial	$92.51

ARIPiprazole 2 mg Tab [KMC]

Facility

$126.92

Service Code	NDC 16714078301
Hospital Revenue Code	250
Min. Negotiated Rate	$107.88
Max. Negotiated Rate	$123.11
Rate for Payer: Cash Price	$82.50
Rate for Payer: Health Management Network Commercial	$107.88
Rate for Payer: Kaiser Permanente Commercial	$114.23
Rate for Payer: MDX Hawaii PPO	$123.11

Know your out-of-pocket cost for care.

All Charges