Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

SBSQ NURSING FACILITY CARE SF MDM 10 MINUTES

Professional

Both

$132.00

Service Code	HCPCS 99307
Hospital Revenue Code	525
Min. Negotiated Rate	$27.59
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$41.45
Rate for Payer: AlohaCare Medicare	$38.02
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$38.02
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: Hawaii Western Management Group Commercial	$27.59
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$45.62
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: Ohana Health Plan Medicaid	$41.45
Rate for Payer: Ohana Health Plan Medicare	$38.02
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

SCALPEL #10

Facility

$6.00

Hospital Charge Code	8256
Hospital Revenue Code	270
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

SCALPEL #10

Facility

$6.00

Hospital Charge Code	8256
Hospital Revenue Code	270
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 Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

SCALPEL #11

Facility

$4.00

Hospital Charge Code	8257
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

SCALPEL #11

Facility

$4.00

Hospital Charge Code	8257
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

SCALPEL #15

Facility

$6.00

Hospital Charge Code	8258
Hospital Revenue Code	270
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 Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

SCALPEL #15

Facility

$6.00

Hospital Charge Code	8258
Hospital Revenue Code	270
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

SCAPULA COMP

Facility

$369.00

Service Code	HCPCS 73010
Hospital Charge Code	424730100
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

SCAPULA COMP

Facility

$369.00

Service Code	HCPCS 73010
Hospital Charge Code	424730100
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	$58.59

SCHROEDER TENAC 9.75"

Facility

$2.00

Hospital Charge Code	8554
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

SCHROEDER TENAC 9.75"

Facility

$2.00

Hospital Charge Code	8554
Hospital Revenue Code	270
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

SCOLIOSIS STUDY SPINE

Facility

$369.00

Service Code	HCPCS 72081
Hospital Charge Code	424720810
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

SCOLIOSIS STUDY SPINE

Facility

$369.00

Service Code	HCPCS 72081
Hospital Charge Code	424720810
Hospital Revenue Code	320
Min. Negotiated Rate	$17.62
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	$17.62
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	$28.37
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$80.07

scopolamine 1 mg/72 hr ER patch [KMC]

Facility

$80.80

Service Code	NDC 50742050504
Hospital Revenue Code	250
Min. Negotiated Rate	$33.94
Max. Negotiated Rate	$78.38
Rate for Payer: AlohaCare Medicaid	$40.40
Rate for Payer: AlohaCare Medicare	$33.94
Rate for Payer: Cash Price	$52.52
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$74.34
Rate for Payer: Devoted Health Medicare	$33.94
Rate for Payer: Hawaii Medical Service Association Medicare	$33.94
Rate for Payer: Hawaii Western Management Group Commercial	$76.76
Rate for Payer: Health Management Network Commercial	$68.68
Rate for Payer: Humana Medicare	$33.94
Rate for Payer: Kaiser Permanente Commercial	$72.72
Rate for Payer: Kaiser Permanente Medicaid	$41.21
Rate for Payer: Kaiser Permanente Medicare	$33.94
Rate for Payer: MDX Hawaii PPO	$78.38
Rate for Payer: Ohana Health Plan Medicaid	$33.94
Rate for Payer: Ohana Health Plan Medicare	$33.94
Rate for Payer: UnitedHealthcare Medicaid	$48.48
Rate for Payer: UnitedHealthcare Medicare	$33.94
Rate for Payer: University Health Alliance Commercial	$58.90

scopolamine 1 mg/72 hr ER patch [KMC]

Facility

$80.80

Service Code	NDC 50742050504
Hospital Revenue Code	250
Min. Negotiated Rate	$68.68
Max. Negotiated Rate	$78.38
Rate for Payer: Cash Price	$52.52
Rate for Payer: Health Management Network Commercial	$68.68
Rate for Payer: Kaiser Permanente Commercial	$72.72
Rate for Payer: MDX Hawaii PPO	$78.38

SCREENING FOR DEPRESSION PERFORMED

Professional

Both

$0.01

Service Code	HCPCS 3725F
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	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
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

SCREENING MAMMOGRAPHY RESULTS DOC&REV

Professional

Both

$0.01

Service Code	HCPCS 3014F
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	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
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

SECONDARY CLOSURE SURG WOUND/DEHSN XTNSV/COMP

Professional

Both

$5,000.00

Service Code	HCPCS 13160
Hospital Revenue Code	361
Min. Negotiated Rate	$312.00
Max. Negotiated Rate	$4,250.00
Rate for Payer: AlohaCare Medicaid	$813.50
Rate for Payer: AlohaCare Medicare	$749.47
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Devoted Health Medicare	$749.47
Rate for Payer: Hawaii Medical Service Association Medicare	$749.47
Rate for Payer: Hawaii Western Management Group Commercial	$312.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$899.36
Rate for Payer: Kaiser Permanente Medicaid	$899.36
Rate for Payer: Kaiser Permanente Medicare	$899.36
Rate for Payer: Ohana Health Plan Medicaid	$813.50
Rate for Payer: Ohana Health Plan Medicare	$749.47
Rate for Payer: UnitedHealthcare Medicaid	$813.50
Rate for Payer: UnitedHealthcare Medicare	$749.47
Rate for Payer: University Health Alliance Commercial	$935.34

Sedimentation Rate

Facility

$91.00

Service Code	HCPCS 85651
Hospital Charge Code	422856510
Hospital Revenue Code	305
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$45.50
Rate for Payer: AlohaCare Medicare	$38.22
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$83.72
Rate for Payer: Devoted Health Medicare	$38.22
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$4.91
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$38.22
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$38.22
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$38.22
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$38.22
Rate for Payer: Ohana Health Plan Medicare	$38.22
Rate for Payer: UnitedHealthcare Medicaid	$4.91
Rate for Payer: UnitedHealthcare Medicare	$38.22
Rate for Payer: University Health Alliance Commercial	$9.18

Sedimentation Rate

Facility

$91.00

Service Code	HCPCS 85651
Hospital Charge Code	422856510
Hospital Revenue Code	305
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$59.15
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: MDX Hawaii PPO	$88.27

Sedimentation Rate DLS

Facility

$17.00

Service Code	HCPCS 85652
Hospital Charge Code	422856525
Hospital Revenue Code	302
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$7.14
Rate for Payer: Cash Price	$11.05
Rate for Payer: Cash Price	$11.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.64
Rate for Payer: Devoted Health Medicare	$7.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$3.73
Rate for Payer: Hawaii Medical Service Association Commercial	$3.38
Rate for Payer: Hawaii Medical Service Association Medicare	$7.14
Rate for Payer: Hawaii Western Management Group Commercial	$2.70
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$7.14
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$7.14
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$7.14
Rate for Payer: Ohana Health Plan Medicare	$7.14
Rate for Payer: UnitedHealthcare Medicaid	$3.73
Rate for Payer: UnitedHealthcare Medicare	$7.14
Rate for Payer: University Health Alliance Commercial	$6.97

Sedimentation Rate DLS

Facility

$17.00

Service Code	HCPCS 85652
Hospital Charge Code	422856525
Hospital Revenue Code	302
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

SEIZURES WITH MCC

Facility

$22,730.22

Service Code	MSDRG 100
Min. Negotiated Rate	$22,730.22
Max. Negotiated Rate	$22,730.22
Rate for Payer: Hawaii Medical Service Association Commercial	$22,730.22

SEIZURES WITHOUT MCC

Facility

$19,625.26

Service Code	MSDRG 101
Min. Negotiated Rate	$19,625.26
Max. Negotiated Rate	$19,625.26
Rate for Payer: Hawaii Medical Service Association Commercial	$19,625.26

Selective Debridement Charge

Facility

$769.00

Service Code	HCPCS 97597 GP
Hospital Charge Code	426975970
Hospital Revenue Code	420
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$745.93
Rate for Payer: AlohaCare Medicaid	$384.50
Rate for Payer: AlohaCare Medicare	$322.98
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$707.48
Rate for Payer: Devoted Health Medicare	$322.98
Rate for Payer: Hawaii Medical Service Association Medicare	$322.98
Rate for Payer: Hawaii Western Management Group Commercial	$730.55
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Humana Medicare	$322.98
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: Kaiser Permanente Medicaid	$392.19
Rate for Payer: Kaiser Permanente Medicare	$322.98
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: Ohana Health Plan Medicaid	$322.98
Rate for Payer: Ohana Health Plan Medicare	$322.98
Rate for Payer: UnitedHealthcare Medicaid	$37.07
Rate for Payer: UnitedHealthcare Medicare	$322.98
Rate for Payer: University Health Alliance Commercial	$560.52

Know your out-of-pocket cost for care.

All Charges