Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Selective Debridement Charge

Facility

$769.00

Service Code	HCPCS 97597 GP
Hospital Charge Code	426975970
Hospital Revenue Code	420
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$499.85
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: MDX Hawaii PPO	$745.93

selegiline 5 mg Cap [KMC]

Facility

$9.21

Service Code	NDC 60505005501
Hospital Revenue Code	250
Min. Negotiated Rate	$7.83
Max. Negotiated Rate	$8.93
Rate for Payer: Cash Price	$5.99
Rate for Payer: Health Management Network Commercial	$7.83
Rate for Payer: Kaiser Permanente Commercial	$8.29
Rate for Payer: MDX Hawaii PPO	$8.93

selegiline 5 mg Cap [KMC]

Facility

$9.21

Service Code	NDC 60505005501
Hospital Revenue Code	250
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$8.93
Rate for Payer: AlohaCare Medicaid	$4.61
Rate for Payer: AlohaCare Medicare	$3.87
Rate for Payer: Cash Price	$5.99
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.47
Rate for Payer: Devoted Health Medicare	$3.87
Rate for Payer: Hawaii Medical Service Association Medicare	$3.87
Rate for Payer: Hawaii Western Management Group Commercial	$8.75
Rate for Payer: Health Management Network Commercial	$7.83
Rate for Payer: Humana Medicare	$3.87
Rate for Payer: Kaiser Permanente Commercial	$8.29
Rate for Payer: Kaiser Permanente Medicaid	$4.70
Rate for Payer: Kaiser Permanente Medicare	$3.87
Rate for Payer: MDX Hawaii PPO	$8.93
Rate for Payer: Ohana Health Plan Medicaid	$3.87
Rate for Payer: Ohana Health Plan Medicare	$3.87
Rate for Payer: UnitedHealthcare Medicaid	$5.53
Rate for Payer: UnitedHealthcare Medicare	$3.87
Rate for Payer: University Health Alliance Commercial	$6.71

selegiline 9 mg/24 hr ER patch [KMC]

Facility

$326.85

Service Code	NDC 49502090130
Hospital Revenue Code	250
Min. Negotiated Rate	$137.28
Max. Negotiated Rate	$317.04
Rate for Payer: AlohaCare Medicaid	$163.43
Rate for Payer: AlohaCare Medicare	$137.28
Rate for Payer: Cash Price	$212.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$300.70
Rate for Payer: Devoted Health Medicare	$137.28
Rate for Payer: Hawaii Medical Service Association Medicare	$137.28
Rate for Payer: Hawaii Western Management Group Commercial	$310.51
Rate for Payer: Health Management Network Commercial	$277.82
Rate for Payer: Humana Medicare	$137.28
Rate for Payer: Kaiser Permanente Commercial	$294.17
Rate for Payer: Kaiser Permanente Medicaid	$166.69
Rate for Payer: Kaiser Permanente Medicare	$137.28
Rate for Payer: MDX Hawaii PPO	$317.04
Rate for Payer: Ohana Health Plan Medicaid	$137.28
Rate for Payer: Ohana Health Plan Medicare	$137.28
Rate for Payer: UnitedHealthcare Medicaid	$196.11
Rate for Payer: UnitedHealthcare Medicare	$137.28
Rate for Payer: University Health Alliance Commercial	$238.24

selegiline 9 mg/24 hr ER patch [KMC]

Facility

$326.85

Service Code	NDC 49502090130
Hospital Revenue Code	250
Min. Negotiated Rate	$277.82
Max. Negotiated Rate	$317.04
Rate for Payer: Cash Price	$212.45
Rate for Payer: Health Management Network Commercial	$277.82
Rate for Payer: Kaiser Permanente Commercial	$294.17
Rate for Payer: MDX Hawaii PPO	$317.04

selenium sulfide 1% Shampoo [KMC]

Facility

$0.09

Service Code	NDC 00536199553
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

selenium sulfide 1% Shampoo [KMC]

Facility

$0.09

Service Code	NDC 00536199553
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

SELF CARE CURRENT STATUS

Professional

Both

$0.01

Service Code	HCPCS G8987
Hospital Revenue Code	420
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

SELF CARE CURRENT STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8987 GO
Hospital Charge Code	426G89870
Hospital Revenue Code	430
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

SELF CARE CURRENT STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8987 GO
Hospital Charge Code	426G89870
Hospital Revenue Code	430
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

SELF CARE CURRENT STATUS Physical

Facility

$1.00

Service Code	HCPCS G8987 GP
Hospital Charge Code	432G89870
Hospital Revenue Code	420
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.65
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

SELF CARE CURRENT STATUS Physical

Facility

$1.00

Service Code	HCPCS G8987 GP
Hospital Charge Code	432G89870
Hospital Revenue Code	420
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.42
Rate for Payer: Cash Price	$0.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.92
Rate for Payer: Devoted Health Medicare	$0.42
Rate for Payer: Hawaii Medical Service Association Medicare	$0.42
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.42
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.42
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.42
Rate for Payer: Ohana Health Plan Medicare	$0.42
Rate for Payer: UnitedHealthcare Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

SELF CARE D/C STATUS

Professional

Both

$0.01

Service Code	HCPCS G8989
Hospital Revenue Code	420
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

SELF CARE D/C STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8989 GO
Hospital Charge Code	426G89890
Hospital Revenue Code	430
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

SELF CARE D/C STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8989 GO
Hospital Charge Code	426G89890
Hospital Revenue Code	430
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

SELF CARE D/C STATUS Physical

Facility

$1.00

Service Code	HCPCS G8989 GP
Hospital Charge Code	432G89890
Hospital Revenue Code	420
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.65
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

SELF CARE D/C STATUS Physical

Facility

$1.00

Service Code	HCPCS G8989 GP
Hospital Charge Code	432G89890
Hospital Revenue Code	420
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.42
Rate for Payer: Cash Price	$0.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.92
Rate for Payer: Devoted Health Medicare	$0.42
Rate for Payer: Hawaii Medical Service Association Medicare	$0.42
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.42
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.42
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.42
Rate for Payer: Ohana Health Plan Medicare	$0.42
Rate for Payer: UnitedHealthcare Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

SELF CARE GOAL STATUS

Professional

Both

$0.01

Service Code	HCPCS G8988
Hospital Revenue Code	420
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

SELF CARE GOAL STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8988 GO
Hospital Charge Code	426G89880
Hospital Revenue Code	430
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

SELF CARE GOAL STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8988 GO
Hospital Charge Code	426G89880
Hospital Revenue Code	430
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

SELF CARE GOAL STATUS Physical

Facility

$1.00

Service Code	HCPCS G8988 GP
Hospital Charge Code	432G89880
Hospital Revenue Code	420
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.97
Rate for Payer: AlohaCare Medicaid	$0.50
Rate for Payer: AlohaCare Medicare	$0.42
Rate for Payer: Cash Price	$0.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.92
Rate for Payer: Devoted Health Medicare	$0.42
Rate for Payer: Hawaii Medical Service Association Medicare	$0.42
Rate for Payer: Hawaii Western Management Group Commercial	$0.95
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Humana Medicare	$0.42
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: Kaiser Permanente Medicaid	$0.51
Rate for Payer: Kaiser Permanente Medicare	$0.42
Rate for Payer: MDX Hawaii PPO	$0.97
Rate for Payer: Ohana Health Plan Medicaid	$0.42
Rate for Payer: Ohana Health Plan Medicare	$0.42
Rate for Payer: UnitedHealthcare Medicare	$0.42
Rate for Payer: University Health Alliance Commercial	$0.73

SELF CARE GOAL STATUS Physical

Facility

$1.00

Service Code	HCPCS G8988 GP
Hospital Charge Code	432G89880
Hospital Revenue Code	420
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.65
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.90
Rate for Payer: MDX Hawaii PPO	$0.97

SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES

Professional

Both

$162.00

Service Code	HCPCS 97535
Hospital Revenue Code	430
Min. Negotiated Rate	$21.27
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$35.05
Rate for Payer: AlohaCare Medicare	$34.59
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$34.59
Rate for Payer: Hawaii Medical Service Association Medicare	$34.59
Rate for Payer: Hawaii Western Management Group Commercial	$21.27
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$41.51
Rate for Payer: Kaiser Permanente Medicaid	$41.51
Rate for Payer: Kaiser Permanente Medicare	$41.51
Rate for Payer: Ohana Health Plan Medicaid	$35.05
Rate for Payer: Ohana Health Plan Medicare	$34.59
Rate for Payer: UnitedHealthcare Medicaid	$35.05
Rate for Payer: UnitedHealthcare Medicare	$34.59

semaglutide 2 mg/1.5 mL Soln [KMC]

Facility

$1,362.56

Service Code	NDC 00169413602
Hospital Revenue Code	250
Min. Negotiated Rate	$1,158.18
Max. Negotiated Rate	$1,321.68
Rate for Payer: Cash Price	$885.66
Rate for Payer: Health Management Network Commercial	$1,158.18
Rate for Payer: Kaiser Permanente Commercial	$1,226.30
Rate for Payer: MDX Hawaii PPO	$1,321.68

semaglutide 2 mg/1.5 mL Soln [KMC]

Facility

$1,362.56

Service Code	NDC 00169413602
Hospital Revenue Code	250
Min. Negotiated Rate	$572.28
Max. Negotiated Rate	$1,321.68
Rate for Payer: AlohaCare Medicaid	$681.28
Rate for Payer: AlohaCare Medicare	$572.28
Rate for Payer: Cash Price	$885.66
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,253.56
Rate for Payer: Devoted Health Medicare	$572.28
Rate for Payer: Hawaii Medical Service Association Medicare	$572.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,294.43
Rate for Payer: Health Management Network Commercial	$1,158.18
Rate for Payer: Humana Medicare	$572.28
Rate for Payer: Kaiser Permanente Commercial	$1,226.30
Rate for Payer: Kaiser Permanente Medicaid	$694.91
Rate for Payer: Kaiser Permanente Medicare	$572.28
Rate for Payer: MDX Hawaii PPO	$1,321.68
Rate for Payer: Ohana Health Plan Medicaid	$572.28
Rate for Payer: Ohana Health Plan Medicare	$572.28
Rate for Payer: UnitedHealthcare Medicaid	$817.54
Rate for Payer: UnitedHealthcare Medicare	$572.28
Rate for Payer: University Health Alliance Commercial	$993.17

Know your out-of-pocket cost for care.

All Charges