Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

SHOULDER IMMOBILIZER SM

Facility

$18.00

Hospital Charge Code	8265
Hospital Revenue Code	270
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$7.56
Rate for Payer: Cash Price	$11.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.56
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$7.56
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$7.56
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$7.56
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$7.56
Rate for Payer: Ohana Health Plan Medicare	$7.56
Rate for Payer: UnitedHealthcare Medicare	$7.56
Rate for Payer: University Health Alliance Commercial	$13.12

SHOULDER IMMOBILIZER SM

Facility

$18.00

Hospital Charge Code	8265
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

SHOULDER IMMOBILIZER XL

Facility

$30.00

Hospital Charge Code	8262
Hospital Revenue Code	270
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$19.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: MDX Hawaii PPO	$29.10

SHOULDER IMMOBILIZER XL

Facility

$30.00

Hospital Charge Code	8262
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$29.10
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$19.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$27.60
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$28.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Humana Medicare	$12.60
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicare	$12.60
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: Ohana Health Plan Medicaid	$12.60
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicare	$12.60
Rate for Payer: University Health Alliance Commercial	$21.87

SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-1.0 CM

Professional

Both

$307.00

Service Code	HCPCS 11311
Hospital Revenue Code	361
Min. Negotiated Rate	$50.78
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$63.34
Rate for Payer: AlohaCare Medicare	$50.78
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$50.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$63.34
Rate for Payer: Hawaii Medical Service Association Commercial	$97.73
Rate for Payer: Hawaii Medical Service Association Medicare	$50.78
Rate for Payer: Hawaii Western Management Group Commercial	$75.40
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$60.94
Rate for Payer: Kaiser Permanente Medicaid	$60.94
Rate for Payer: Kaiser Permanente Medicare	$60.94
Rate for Payer: Ohana Health Plan Medicaid	$63.34
Rate for Payer: Ohana Health Plan Medicare	$50.78
Rate for Payer: UnitedHealthcare Medicaid	$63.34
Rate for Payer: UnitedHealthcare Medicare	$50.78
Rate for Payer: University Health Alliance Commercial	$72.32

SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 1.1-2.0 CM

Professional

Both

$540.00

Service Code	HCPCS 11312
Hospital Revenue Code	361
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$459.00
Rate for Payer: AlohaCare Medicaid	$74.96
Rate for Payer: AlohaCare Medicare	$60.50
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$60.50
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$74.96
Rate for Payer: Hawaii Medical Service Association Commercial	$115.68
Rate for Payer: Hawaii Medical Service Association Medicare	$60.50
Rate for Payer: Hawaii Western Management Group Commercial	$91.26
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$72.60
Rate for Payer: Kaiser Permanente Medicaid	$72.60
Rate for Payer: Kaiser Permanente Medicare	$72.60
Rate for Payer: Ohana Health Plan Medicaid	$74.96
Rate for Payer: Ohana Health Plan Medicare	$60.50
Rate for Payer: UnitedHealthcare Medicaid	$74.96
Rate for Payer: UnitedHealthcare Medicare	$60.50
Rate for Payer: University Health Alliance Commercial	$85.60

SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM

Professional

Both

$307.00

Service Code	HCPCS 11301
Hospital Revenue Code	361
Min. Negotiated Rate	$41.95
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$51.71
Rate for Payer: AlohaCare Medicare	$41.95
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$41.95
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$51.71
Rate for Payer: Hawaii Medical Service Association Commercial	$80.01
Rate for Payer: Hawaii Medical Service Association Medicare	$41.95
Rate for Payer: Hawaii Western Management Group Commercial	$61.62
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$50.34
Rate for Payer: Kaiser Permanente Medicaid	$50.34
Rate for Payer: Kaiser Permanente Medicare	$50.34
Rate for Payer: Ohana Health Plan Medicaid	$51.71
Rate for Payer: Ohana Health Plan Medicare	$41.95
Rate for Payer: UnitedHealthcare Medicaid	$51.71
Rate for Payer: UnitedHealthcare Medicare	$41.95
Rate for Payer: University Health Alliance Commercial	$59.21

SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2.0 CM

Professional

Both

$540.00

Service Code	HCPCS 11303
Hospital Revenue Code	361
Min. Negotiated Rate	$57.69
Max. Negotiated Rate	$459.00
Rate for Payer: AlohaCare Medicaid	$71.76
Rate for Payer: AlohaCare Medicare	$57.69
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$57.69
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$71.76
Rate for Payer: Hawaii Medical Service Association Commercial	$110.69
Rate for Payer: Hawaii Medical Service Association Medicare	$57.69
Rate for Payer: Hawaii Western Management Group Commercial	$95.42
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$69.23
Rate for Payer: Kaiser Permanente Medicaid	$69.23
Rate for Payer: Kaiser Permanente Medicare	$69.23
Rate for Payer: Ohana Health Plan Medicaid	$71.76
Rate for Payer: Ohana Health Plan Medicare	$57.69
Rate for Payer: UnitedHealthcare Medicaid	$71.76
Rate for Payer: UnitedHealthcare Medicare	$57.69
Rate for Payer: University Health Alliance Commercial	$81.91

SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1-2.0 CM

Professional

Both

$307.00

Service Code	HCPCS 11302
Hospital Revenue Code	361
Min. Negotiated Rate	$48.72
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$60.34
Rate for Payer: AlohaCare Medicare	$48.72
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$48.72
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$60.34
Rate for Payer: Hawaii Medical Service Association Commercial	$93.92
Rate for Payer: Hawaii Medical Service Association Medicare	$48.72
Rate for Payer: Hawaii Western Management Group Commercial	$77.22
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$58.46
Rate for Payer: Kaiser Permanente Medicaid	$58.46
Rate for Payer: Kaiser Permanente Medicare	$58.46
Rate for Payer: Ohana Health Plan Medicaid	$60.34
Rate for Payer: Ohana Health Plan Medicare	$48.72
Rate for Payer: UnitedHealthcare Medicaid	$60.34
Rate for Payer: UnitedHealthcare Medicare	$48.72
Rate for Payer: University Health Alliance Commercial	$69.50

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$10,499.99

Service Code	MSDRG 555
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$10,499.99

Service Code	MSDRG 556
Min. Negotiated Rate	$10,499.99
Max. Negotiated Rate	$10,499.99
Rate for Payer: Hawaii Medical Service Association Commercial	$10,499.99

SIGNS AND SYMPTOMS WITH MCC

Facility

$14,387.11

Service Code	MSDRG 947
Min. Negotiated Rate	$14,387.11
Max. Negotiated Rate	$14,387.11
Rate for Payer: Hawaii Medical Service Association Commercial	$14,387.11

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$13,676.05

Service Code	MSDRG 948
Min. Negotiated Rate	$13,676.05
Max. Negotiated Rate	$13,676.05
Rate for Payer: Hawaii Medical Service Association Commercial	$13,676.05

sildenafil 20 mg Tab[KMC]

Facility

$3.00

Service Code	NDC 16714033801
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

sildenafil 20 mg Tab[KMC]

Facility

$3.00

Service Code	NDC 16714033801
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

silodosin 4 mg Cap [KMC]

Facility

$35.89

Service Code	NDC 69238142103
Hospital Revenue Code	250
Min. Negotiated Rate	$30.51
Max. Negotiated Rate	$34.81
Rate for Payer: Cash Price	$23.33
Rate for Payer: Health Management Network Commercial	$30.51
Rate for Payer: Kaiser Permanente Commercial	$32.30
Rate for Payer: MDX Hawaii PPO	$34.81

silodosin 4 mg Cap [KMC]

Facility

$35.89

Service Code	NDC 69238142103
Hospital Revenue Code	250
Min. Negotiated Rate	$15.07
Max. Negotiated Rate	$34.81
Rate for Payer: AlohaCare Medicaid	$17.95
Rate for Payer: AlohaCare Medicare	$15.07
Rate for Payer: Cash Price	$23.33
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.02
Rate for Payer: Devoted Health Medicare	$15.07
Rate for Payer: Hawaii Medical Service Association Medicare	$15.07
Rate for Payer: Hawaii Western Management Group Commercial	$34.10
Rate for Payer: Health Management Network Commercial	$30.51
Rate for Payer: Humana Medicare	$15.07
Rate for Payer: Kaiser Permanente Commercial	$32.30
Rate for Payer: Kaiser Permanente Medicaid	$18.30
Rate for Payer: Kaiser Permanente Medicare	$15.07
Rate for Payer: MDX Hawaii PPO	$34.81
Rate for Payer: Ohana Health Plan Medicaid	$15.07
Rate for Payer: Ohana Health Plan Medicare	$15.07
Rate for Payer: UnitedHealthcare Medicaid	$21.53
Rate for Payer: UnitedHealthcare Medicare	$15.07
Rate for Payer: University Health Alliance Commercial	$26.16

silodosin 8 mg Cap [KMC]

Facility

$35.89

Service Code	NDC 59651009690
Hospital Revenue Code	250
Min. Negotiated Rate	$15.07
Max. Negotiated Rate	$34.81
Rate for Payer: AlohaCare Medicaid	$17.95
Rate for Payer: AlohaCare Medicare	$15.07
Rate for Payer: Cash Price	$23.33
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.02
Rate for Payer: Devoted Health Medicare	$15.07
Rate for Payer: Hawaii Medical Service Association Medicare	$15.07
Rate for Payer: Hawaii Western Management Group Commercial	$34.10
Rate for Payer: Health Management Network Commercial	$30.51
Rate for Payer: Humana Medicare	$15.07
Rate for Payer: Kaiser Permanente Commercial	$32.30
Rate for Payer: Kaiser Permanente Medicaid	$18.30
Rate for Payer: Kaiser Permanente Medicare	$15.07
Rate for Payer: MDX Hawaii PPO	$34.81
Rate for Payer: Ohana Health Plan Medicaid	$15.07
Rate for Payer: Ohana Health Plan Medicare	$15.07
Rate for Payer: UnitedHealthcare Medicaid	$21.53
Rate for Payer: UnitedHealthcare Medicare	$15.07
Rate for Payer: University Health Alliance Commercial	$26.16

silodosin 8 mg Cap [KMC]

Facility

$35.89

Service Code	NDC 59651009690
Hospital Revenue Code	250
Min. Negotiated Rate	$30.51
Max. Negotiated Rate	$34.81
Rate for Payer: Cash Price	$23.33
Rate for Payer: Health Management Network Commercial	$30.51
Rate for Payer: Kaiser Permanente Commercial	$32.30
Rate for Payer: MDX Hawaii PPO	$34.81

silver nitrate Top Stick [KMC]

Facility

$3.14

Service Code	NDC 12870000102
Hospital Revenue Code	250
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.05
Rate for Payer: Cash Price	$2.04
Rate for Payer: Health Management Network Commercial	$2.67
Rate for Payer: Kaiser Permanente Commercial	$2.83
Rate for Payer: MDX Hawaii PPO	$3.05

silver nitrate Top Stick [KMC]

Facility

$3.14

Service Code	NDC 12870000102
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$3.05
Rate for Payer: AlohaCare Medicaid	$1.57
Rate for Payer: AlohaCare Medicare	$1.32
Rate for Payer: Cash Price	$2.04
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.89
Rate for Payer: Devoted Health Medicare	$1.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$2.98
Rate for Payer: Health Management Network Commercial	$2.67
Rate for Payer: Humana Medicare	$1.32
Rate for Payer: Kaiser Permanente Commercial	$2.83
Rate for Payer: Kaiser Permanente Medicaid	$1.60
Rate for Payer: Kaiser Permanente Medicare	$1.32
Rate for Payer: MDX Hawaii PPO	$3.05
Rate for Payer: Ohana Health Plan Medicaid	$1.32
Rate for Payer: Ohana Health Plan Medicare	$1.32
Rate for Payer: UnitedHealthcare Medicaid	$1.88
Rate for Payer: UnitedHealthcare Medicare	$1.32
Rate for Payer: University Health Alliance Commercial	$2.29

silver sulfADIAZINE 1% Cream [KMC]

Facility

$1.45

Service Code	NDC 59762013102
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.41
Rate for Payer: AlohaCare Medicaid	$0.73
Rate for Payer: AlohaCare Medicare	$0.61
Rate for Payer: Cash Price	$0.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.33
Rate for Payer: Devoted Health Medicare	$0.61
Rate for Payer: Hawaii Medical Service Association Medicare	$0.61
Rate for Payer: Hawaii Western Management Group Commercial	$1.38
Rate for Payer: Health Management Network Commercial	$1.23
Rate for Payer: Humana Medicare	$0.61
Rate for Payer: Kaiser Permanente Commercial	$1.30
Rate for Payer: Kaiser Permanente Medicaid	$0.74
Rate for Payer: Kaiser Permanente Medicare	$0.61
Rate for Payer: MDX Hawaii PPO	$1.41
Rate for Payer: Ohana Health Plan Medicaid	$0.61
Rate for Payer: Ohana Health Plan Medicare	$0.61
Rate for Payer: UnitedHealthcare Medicaid	$0.87
Rate for Payer: UnitedHealthcare Medicare	$0.61
Rate for Payer: University Health Alliance Commercial	$1.06

silver sulfADIAZINE 1% Cream [KMC]

Facility

$1.45

Service Code	NDC 59762013102
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.41
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Management Network Commercial	$1.23
Rate for Payer: Kaiser Permanente Commercial	$1.30
Rate for Payer: MDX Hawaii PPO	$1.41

silver topical - Gel [KMC]

Facility

$2.72

Service Code	NDC 08327030909
Hospital Revenue Code	250
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$2.64
Rate for Payer: AlohaCare Medicaid	$1.36
Rate for Payer: AlohaCare Medicare	$1.14
Rate for Payer: Cash Price	$1.77
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.50
Rate for Payer: Devoted Health Medicare	$1.14
Rate for Payer: Hawaii Medical Service Association Medicare	$1.14
Rate for Payer: Hawaii Western Management Group Commercial	$2.58
Rate for Payer: Health Management Network Commercial	$2.31
Rate for Payer: Humana Medicare	$1.14
Rate for Payer: Kaiser Permanente Commercial	$2.45
Rate for Payer: Kaiser Permanente Medicaid	$1.39
Rate for Payer: Kaiser Permanente Medicare	$1.14
Rate for Payer: MDX Hawaii PPO	$2.64
Rate for Payer: Ohana Health Plan Medicaid	$1.14
Rate for Payer: Ohana Health Plan Medicare	$1.14
Rate for Payer: UnitedHealthcare Medicaid	$1.63
Rate for Payer: UnitedHealthcare Medicare	$1.14
Rate for Payer: University Health Alliance Commercial	$1.98

silver topical - Gel [KMC]

Facility

$2.72

Service Code	NDC 08327030909
Hospital Revenue Code	250
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$2.64
Rate for Payer: Cash Price	$1.77
Rate for Payer: Health Management Network Commercial	$2.31
Rate for Payer: Kaiser Permanente Commercial	$2.45
Rate for Payer: MDX Hawaii PPO	$2.64

Know your out-of-pocket cost for care.

All Charges