Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

senna 8.6 mg Tab UD

Facility

$3.00

Service Code	NDC 00904652261
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

senna 8.6 mg Tab UD

Facility

$3.00

Service Code	NDC 00904652261
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

SENSORY INTEGRAT EA 15MIN Occupational

Facility

$179.00

Service Code	HCPCS 97533 GO
Hospital Charge Code	432975330
Hospital Revenue Code	430
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

SENSORY INTEGRAT EA 15MIN Occupational

Facility

$179.00

Service Code	HCPCS 97533 GO
Hospital Charge Code	432975330
Hospital Revenue Code	430
Min. Negotiated Rate	$17.81
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

SENSORY INTEGRAT EA 15MIN Physical

Facility

$179.00

Service Code	HCPCS 97533 GP
Hospital Charge Code	432975330
Hospital Revenue Code	420
Min. Negotiated Rate	$17.81
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

SENSORY INTEGRAT EA 15MIN Physical

Facility

$179.00

Service Code	HCPCS 97533 GP
Hospital Charge Code	432975330
Hospital Revenue Code	420
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

SENSORY INTEGRATIVE TECHNIQUES EACH 15 MINUTES

Professional

Both

$162.00

Service Code	HCPCS 97533
Hospital Revenue Code	430
Min. Negotiated Rate	$27.26
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$68.95
Rate for Payer: AlohaCare Medicare	$66.73
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$66.73
Rate for Payer: Hawaii Medical Service Association Medicare	$66.73
Rate for Payer: Hawaii Western Management Group Commercial	$27.26
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$80.08
Rate for Payer: Kaiser Permanente Medicaid	$80.08
Rate for Payer: Kaiser Permanente Medicare	$80.08
Rate for Payer: Ohana Health Plan Medicaid	$68.95
Rate for Payer: Ohana Health Plan Medicare	$66.73
Rate for Payer: UnitedHealthcare Medicaid	$68.95
Rate for Payer: UnitedHealthcare Medicare	$66.73

Sensory Stimulation Charge

Facility

$179.00

Service Code	HCPCS 97533 GO
Hospital Charge Code	432975330
Hospital Revenue Code	430
Min. Negotiated Rate	$17.81
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

Sensory Stimulation Charge

Facility

$179.00

Service Code	HCPCS 97533 GO
Hospital Charge Code	432975330
Hospital Revenue Code	430
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

SEPTIC ARTHRITIS WITH CC

Facility

$24,460.46

Service Code	MSDRG 549
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTIC ARTHRITIS WITH MCC

Facility

$24,460.46

Service Code	MSDRG 548
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTIC ARTHRITIS WITHOUT CC/MCC

Facility

$24,460.46

Service Code	MSDRG 550
Min. Negotiated Rate	$24,460.46
Max. Negotiated Rate	$24,460.46
Rate for Payer: Hawaii Medical Service Association Commercial	$24,460.46

SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS

Facility

$182,695.02

Service Code	MSDRG 870
Min. Negotiated Rate	$182,695.02
Max. Negotiated Rate	$182,695.02
Rate for Payer: Hawaii Medical Service Association Commercial	$182,695.02

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC

Facility

$40,814.84

Service Code	MSDRG 871
Min. Negotiated Rate	$40,814.84
Max. Negotiated Rate	$40,814.84
Rate for Payer: Hawaii Medical Service Association Commercial	$40,814.84

SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC

Facility

$40,791.14

Service Code	MSDRG 872
Min. Negotiated Rate	$40,791.14
Max. Negotiated Rate	$40,791.14
Rate for Payer: Hawaii Medical Service Association Commercial	$40,791.14

sertraline 100 mg Tab [KMC]

Facility

$11.39

Service Code	NDC 16714061301
Hospital Revenue Code	250
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$7.40
Rate for Payer: Health Management Network Commercial	$9.68
Rate for Payer: Kaiser Permanente Commercial	$10.25
Rate for Payer: MDX Hawaii PPO	$11.05

sertraline 100 mg Tab [KMC]

Facility

$11.39

Service Code	NDC 16714061301
Hospital Revenue Code	250
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$11.05
Rate for Payer: AlohaCare Medicaid	$5.70
Rate for Payer: AlohaCare Medicare	$4.78
Rate for Payer: Cash Price	$7.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.48
Rate for Payer: Devoted Health Medicare	$4.78
Rate for Payer: Hawaii Medical Service Association Medicare	$4.78
Rate for Payer: Hawaii Western Management Group Commercial	$10.82
Rate for Payer: Health Management Network Commercial	$9.68
Rate for Payer: Humana Medicare	$4.78
Rate for Payer: Kaiser Permanente Commercial	$10.25
Rate for Payer: Kaiser Permanente Medicaid	$5.81
Rate for Payer: Kaiser Permanente Medicare	$4.78
Rate for Payer: MDX Hawaii PPO	$11.05
Rate for Payer: Ohana Health Plan Medicaid	$4.78
Rate for Payer: Ohana Health Plan Medicare	$4.78
Rate for Payer: UnitedHealthcare Medicaid	$6.83
Rate for Payer: UnitedHealthcare Medicare	$4.78
Rate for Payer: University Health Alliance Commercial	$8.30

sertraline 50 mg Tab [KMC]

Facility

$11.39

Service Code	NDC 16729021615
Hospital Revenue Code	250
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$7.40
Rate for Payer: Health Management Network Commercial	$9.68
Rate for Payer: Kaiser Permanente Commercial	$10.25
Rate for Payer: MDX Hawaii PPO	$11.05

sertraline 50 mg Tab [KMC]

Facility

$11.39

Service Code	NDC 16729021615
Hospital Revenue Code	250
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$11.05
Rate for Payer: AlohaCare Medicaid	$5.70
Rate for Payer: AlohaCare Medicare	$4.78
Rate for Payer: Cash Price	$7.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.48
Rate for Payer: Devoted Health Medicare	$4.78
Rate for Payer: Hawaii Medical Service Association Medicare	$4.78
Rate for Payer: Hawaii Western Management Group Commercial	$10.82
Rate for Payer: Health Management Network Commercial	$9.68
Rate for Payer: Humana Medicare	$4.78
Rate for Payer: Kaiser Permanente Commercial	$10.25
Rate for Payer: Kaiser Permanente Medicaid	$5.81
Rate for Payer: Kaiser Permanente Medicare	$4.78
Rate for Payer: MDX Hawaii PPO	$11.05
Rate for Payer: Ohana Health Plan Medicaid	$4.78
Rate for Payer: Ohana Health Plan Medicare	$4.78
Rate for Payer: UnitedHealthcare Medicaid	$6.83
Rate for Payer: UnitedHealthcare Medicare	$4.78
Rate for Payer: University Health Alliance Commercial	$8.30

Serum Protein ELP DLS

Facility

$57.00

Service Code	HCPCS 84165
Hospital Charge Code	422841655
Hospital Revenue Code	301
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$55.29
Rate for Payer: AlohaCare Medicaid	$28.50
Rate for Payer: AlohaCare Medicare	$23.94
Rate for Payer: Cash Price	$37.05
Rate for Payer: Cash Price	$37.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$52.44
Rate for Payer: Devoted Health Medicare	$23.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13.43
Rate for Payer: Hawaii Medical Service Association Medicare	$23.94
Rate for Payer: Hawaii Western Management Group Commercial	$10.74
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Humana Medicare	$23.94
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: Kaiser Permanente Medicaid	$29.07
Rate for Payer: Kaiser Permanente Medicare	$23.94
Rate for Payer: MDX Hawaii PPO	$55.29
Rate for Payer: Ohana Health Plan Medicaid	$23.94
Rate for Payer: Ohana Health Plan Medicare	$23.94
Rate for Payer: UnitedHealthcare Medicaid	$14.84
Rate for Payer: UnitedHealthcare Medicare	$23.94
Rate for Payer: University Health Alliance Commercial	$27.77

Serum Protein ELP DLS

Facility

$57.00

Service Code	HCPCS 84165
Hospital Charge Code	422841655
Hospital Revenue Code	301
Min. Negotiated Rate	$48.45
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$37.05
Rate for Payer: Health Management Network Commercial	$48.45
Rate for Payer: Kaiser Permanente Commercial	$51.30
Rate for Payer: MDX Hawaii PPO	$55.29

sevelamer carbonate 2.4 g REC powder packet [KMC]

Facility

$42.94

Service Code	NDC 58468013102
Hospital Revenue Code	250
Min. Negotiated Rate	$36.50
Max. Negotiated Rate	$41.65
Rate for Payer: Cash Price	$27.91
Rate for Payer: Health Management Network Commercial	$36.50
Rate for Payer: Kaiser Permanente Commercial	$38.65
Rate for Payer: MDX Hawaii PPO	$41.65

sevelamer carbonate 2.4 g REC powder packet [KMC]

Facility

$42.94

Service Code	NDC 58468013102
Hospital Revenue Code	250
Min. Negotiated Rate	$18.03
Max. Negotiated Rate	$41.65
Rate for Payer: AlohaCare Medicaid	$21.47
Rate for Payer: AlohaCare Medicare	$18.03
Rate for Payer: Cash Price	$27.91
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$39.50
Rate for Payer: Devoted Health Medicare	$18.03
Rate for Payer: Hawaii Medical Service Association Medicare	$18.03
Rate for Payer: Hawaii Western Management Group Commercial	$40.79
Rate for Payer: Health Management Network Commercial	$36.50
Rate for Payer: Humana Medicare	$18.03
Rate for Payer: Kaiser Permanente Commercial	$38.65
Rate for Payer: Kaiser Permanente Medicaid	$21.90
Rate for Payer: Kaiser Permanente Medicare	$18.03
Rate for Payer: MDX Hawaii PPO	$41.65
Rate for Payer: Ohana Health Plan Medicaid	$18.03
Rate for Payer: Ohana Health Plan Medicare	$18.03
Rate for Payer: UnitedHealthcare Medicaid	$25.76
Rate for Payer: UnitedHealthcare Medicare	$18.03
Rate for Payer: University Health Alliance Commercial	$31.30

sevelamer carbonate 800 mg Tab [KMC]

Facility

$18.34

Service Code	NDC 16714081401
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$17.79
Rate for Payer: AlohaCare Medicaid	$9.17
Rate for Payer: AlohaCare Medicare	$7.70
Rate for Payer: Cash Price	$11.92
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.87
Rate for Payer: Devoted Health Medicare	$7.70
Rate for Payer: Hawaii Medical Service Association Medicare	$7.70
Rate for Payer: Hawaii Western Management Group Commercial	$17.42
Rate for Payer: Health Management Network Commercial	$15.59
Rate for Payer: Humana Medicare	$7.70
Rate for Payer: Kaiser Permanente Commercial	$16.51
Rate for Payer: Kaiser Permanente Medicaid	$9.35
Rate for Payer: Kaiser Permanente Medicare	$7.70
Rate for Payer: MDX Hawaii PPO	$17.79
Rate for Payer: Ohana Health Plan Medicaid	$7.70
Rate for Payer: Ohana Health Plan Medicare	$7.70
Rate for Payer: UnitedHealthcare Medicaid	$11.00
Rate for Payer: UnitedHealthcare Medicare	$7.70
Rate for Payer: University Health Alliance Commercial	$13.37

sevelamer carbonate 800 mg Tab [KMC]

Facility

$18.34

Service Code	NDC 16714081401
Hospital Revenue Code	250
Min. Negotiated Rate	$15.59
Max. Negotiated Rate	$17.79
Rate for Payer: Cash Price	$11.92
Rate for Payer: Health Management Network Commercial	$15.59
Rate for Payer: Kaiser Permanente Commercial	$16.51
Rate for Payer: MDX Hawaii PPO	$17.79

Know your out-of-pocket cost for care.

All Charges