Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

SIMPLE LAC FACE 7.6-12.5 ED Charge

Facility

$429.00

Service Code	HCPCS 12015
Hospital Charge Code	440120150
Hospital Revenue Code	450
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

SIMPLE LAC SCP/NK>30 CM ED Charge

Facility

$429.00

Service Code	HCPCS 12007
Hospital Charge Code	440120070
Hospital Revenue Code	450
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$180.18
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$394.68
Rate for Payer: Devoted Health Medicare	$180.18
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	$180.18
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$180.18
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$180.18
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$180.18
Rate for Payer: Ohana Health Plan Medicare	$180.18
Rate for Payer: UnitedHealthcare Medicare	$180.18
Rate for Payer: University Health Alliance Commercial	$312.70

SIMPLE LAC SCP/NK>30 CM ED Charge

Facility

$429.00

Service Code	HCPCS 12007
Hospital Charge Code	440120070
Hospital Revenue Code	450
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$23,796.81

Service Code	MSDRG 194
Min. Negotiated Rate	$23,796.81
Max. Negotiated Rate	$23,796.81
Rate for Payer: Hawaii Medical Service Association Commercial	$23,796.81

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$24,626.38

Service Code	MSDRG 193
Min. Negotiated Rate	$24,626.38
Max. Negotiated Rate	$24,626.38
Rate for Payer: Hawaii Medical Service Association Commercial	$24,626.38

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$18,937.90

Service Code	MSDRG 195
Min. Negotiated Rate	$18,937.90
Max. Negotiated Rate	$18,937.90
Rate for Payer: Hawaii Medical Service Association Commercial	$18,937.90

SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM

Professional

Both

$307.00

Service Code	HCPCS 12016
Hospital Revenue Code	361
Min. Negotiated Rate	$115.68
Max. Negotiated Rate	$279.03
Rate for Payer: AlohaCare Medicaid	$121.86
Rate for Payer: AlohaCare Medicare	$115.68
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$115.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$121.86
Rate for Payer: Hawaii Medical Service Association Commercial	$279.03
Rate for Payer: Hawaii Medical Service Association Medicare	$115.68
Rate for Payer: Hawaii Western Management Group Commercial	$184.60
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$138.82
Rate for Payer: Kaiser Permanente Medicaid	$138.82
Rate for Payer: Kaiser Permanente Medicare	$138.82
Rate for Payer: Ohana Health Plan Medicaid	$121.86
Rate for Payer: Ohana Health Plan Medicare	$115.68
Rate for Payer: UnitedHealthcare Medicaid	$121.86
Rate for Payer: UnitedHealthcare Medicare	$115.68
Rate for Payer: University Health Alliance Commercial	$144.24

SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0 CM

Professional

Both

$307.00

Service Code	HCPCS 12017
Hospital Revenue Code	361
Min. Negotiated Rate	$146.66
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$146.66
Rate for Payer: AlohaCare Medicare	$146.73
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$146.73
Rate for Payer: Hawaii Medical Service Association Medicare	$146.73
Rate for Payer: Hawaii Western Management Group Commercial	$245.70
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$176.08
Rate for Payer: Kaiser Permanente Medicaid	$176.08
Rate for Payer: Kaiser Permanente Medicare	$176.08
Rate for Payer: Ohana Health Plan Medicaid	$146.66
Rate for Payer: Ohana Health Plan Medicare	$146.73
Rate for Payer: UnitedHealthcare Medicaid	$146.66
Rate for Payer: UnitedHealthcare Medicare	$146.73

SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<

Professional

Both

$307.00

Service Code	HCPCS 12011
Hospital Revenue Code	361
Min. Negotiated Rate	$52.86
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$54.07
Rate for Payer: AlohaCare Medicare	$52.86
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$52.86
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$54.07
Rate for Payer: Hawaii Medical Service Association Commercial	$135.93
Rate for Payer: Hawaii Medical Service Association Medicare	$52.86
Rate for Payer: Hawaii Western Management Group Commercial	$106.08
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$63.43
Rate for Payer: Kaiser Permanente Medicaid	$63.43
Rate for Payer: Kaiser Permanente Medicare	$63.43
Rate for Payer: Ohana Health Plan Medicaid	$54.07
Rate for Payer: Ohana Health Plan Medicare	$52.86
Rate for Payer: UnitedHealthcare Medicaid	$54.07
Rate for Payer: UnitedHealthcare Medicare	$52.86
Rate for Payer: University Health Alliance Commercial	$62.33

SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM

Professional

Both

$307.00

Service Code	HCPCS 12013
Hospital Revenue Code	361
Min. Negotiated Rate	$52.94
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$55.42
Rate for Payer: AlohaCare Medicare	$52.94
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$52.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$55.42
Rate for Payer: Hawaii Medical Service Association Commercial	$155.51
Rate for Payer: Hawaii Medical Service Association Medicare	$52.94
Rate for Payer: Hawaii Western Management Group Commercial	$125.06
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$63.53
Rate for Payer: Kaiser Permanente Medicaid	$63.53
Rate for Payer: Kaiser Permanente Medicare	$63.53
Rate for Payer: Ohana Health Plan Medicaid	$55.42
Rate for Payer: Ohana Health Plan Medicare	$52.94
Rate for Payer: UnitedHealthcare Medicaid	$55.42
Rate for Payer: UnitedHealthcare Medicare	$52.94

SIMPLE REPAIR F/E/E/N/L/M >30.0 CM

Professional

Both

$307.00

Service Code	HCPCS 12018
Hospital Revenue Code	361
Min. Negotiated Rate	$165.14
Max. Negotiated Rate	$320.84
Rate for Payer: AlohaCare Medicaid	$165.14
Rate for Payer: AlohaCare Medicare	$165.35
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$165.35
Rate for Payer: Hawaii Medical Service Association Medicare	$165.35
Rate for Payer: Hawaii Western Management Group Commercial	$320.84
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$198.42
Rate for Payer: Kaiser Permanente Medicaid	$198.42
Rate for Payer: Kaiser Permanente Medicare	$198.42
Rate for Payer: Ohana Health Plan Medicaid	$165.14
Rate for Payer: Ohana Health Plan Medicare	$165.35
Rate for Payer: UnitedHealthcare Medicaid	$165.14
Rate for Payer: UnitedHealthcare Medicare	$165.35

SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM

Professional

Both

$307.00

Service Code	HCPCS 12014
Hospital Revenue Code	361
Min. Negotiated Rate	$68.32
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$71.62
Rate for Payer: AlohaCare Medicare	$68.32
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$68.32
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$71.62
Rate for Payer: Hawaii Medical Service Association Commercial	$185.08
Rate for Payer: Hawaii Medical Service Association Medicare	$68.32
Rate for Payer: Hawaii Western Management Group Commercial	$149.50
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$81.98
Rate for Payer: Kaiser Permanente Medicaid	$81.98
Rate for Payer: Kaiser Permanente Medicare	$81.98
Rate for Payer: Ohana Health Plan Medicaid	$71.62
Rate for Payer: Ohana Health Plan Medicare	$68.32
Rate for Payer: UnitedHealthcare Medicaid	$71.62
Rate for Payer: UnitedHealthcare Medicare	$68.32
Rate for Payer: University Health Alliance Commercial	$83.44

SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM

Professional

Both

$307.00

Service Code	HCPCS 12015
Hospital Revenue Code	361
Min. Negotiated Rate	$85.51
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$89.83
Rate for Payer: AlohaCare Medicare	$85.51
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$85.51
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$89.83
Rate for Payer: Hawaii Medical Service Association Commercial	$231.30
Rate for Payer: Hawaii Medical Service Association Medicare	$85.51
Rate for Payer: Hawaii Western Management Group Commercial	$147.16
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$102.61
Rate for Payer: Kaiser Permanente Medicaid	$102.61
Rate for Payer: Kaiser Permanente Medicare	$102.61
Rate for Payer: Ohana Health Plan Medicaid	$89.83
Rate for Payer: Ohana Health Plan Medicare	$85.51
Rate for Payer: UnitedHealthcare Medicaid	$89.83
Rate for Payer: UnitedHealthcare Medicare	$85.51
Rate for Payer: University Health Alliance Commercial	$105.37

SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<

Professional

Both

$307.00

Service Code	HCPCS 12001
Hospital Revenue Code	361
Min. Negotiated Rate	$43.02
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$43.95
Rate for Payer: AlohaCare Medicare	$43.02
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$43.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$43.95
Rate for Payer: Hawaii Medical Service Association Commercial	$131.08
Rate for Payer: Hawaii Medical Service Association Medicare	$43.02
Rate for Payer: Hawaii Western Management Group Commercial	$83.46
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$51.62
Rate for Payer: Kaiser Permanente Medicaid	$51.62
Rate for Payer: Kaiser Permanente Medicare	$51.62
Rate for Payer: Ohana Health Plan Medicaid	$43.95
Rate for Payer: Ohana Health Plan Medicare	$43.02
Rate for Payer: UnitedHealthcare Medicaid	$43.95
Rate for Payer: UnitedHealthcare Medicare	$43.02
Rate for Payer: University Health Alliance Commercial	$131.00

SIMPLE REP SUPERFIC<2.5CM ED Charge

Facility

$678.00

Service Code	HCPCS 12011
Hospital Charge Code	440120110
Hospital Revenue Code	450
Min. Negotiated Rate	$576.30
Max. Negotiated Rate	$657.66
Rate for Payer: Cash Price	$440.70
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: MDX Hawaii PPO	$657.66

SIMPLE REP SUPERFIC<2.5CM ED Charge

Facility

$678.00

Service Code	HCPCS 12011
Hospital Charge Code	440120110
Hospital Revenue Code	450
Min. Negotiated Rate	$284.76
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$339.00
Rate for Payer: AlohaCare Medicare	$284.76
Rate for Payer: Cash Price	$440.70
Rate for Payer: Cash Price	$440.70
Rate for Payer: Cash Price	$440.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$623.76
Rate for Payer: Devoted Health Medicare	$284.76
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	$284.76
Rate for Payer: Hawaii Western Management Group Commercial	$644.10
Rate for Payer: Health Management Network Commercial	$576.30
Rate for Payer: Humana Medicare	$284.76
Rate for Payer: Kaiser Permanente Commercial	$610.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$284.76
Rate for Payer: MDX Hawaii PPO	$657.66
Rate for Payer: Ohana Health Plan Medicaid	$284.76
Rate for Payer: Ohana Health Plan Medicare	$284.76
Rate for Payer: UnitedHealthcare Medicare	$284.76
Rate for Payer: University Health Alliance Commercial	$494.19

SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM

Professional

Both

$307.00

Service Code	HCPCS 12004
Hospital Revenue Code	361
Min. Negotiated Rate	$69.47
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$71.33
Rate for Payer: AlohaCare Medicare	$69.47
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$69.47
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$71.33
Rate for Payer: Hawaii Medical Service Association Commercial	$170.75
Rate for Payer: Hawaii Medical Service Association Medicare	$69.47
Rate for Payer: Hawaii Western Management Group Commercial	$138.06
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$83.36
Rate for Payer: Kaiser Permanente Medicaid	$83.36
Rate for Payer: Kaiser Permanente Medicare	$83.36
Rate for Payer: Ohana Health Plan Medicaid	$71.33
Rate for Payer: Ohana Health Plan Medicare	$69.47
Rate for Payer: UnitedHealthcare Medicaid	$71.33
Rate for Payer: UnitedHealthcare Medicare	$69.47
Rate for Payer: University Health Alliance Commercial	$82.18

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$696,862.50

Service Code	MSDRG 008
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$696,862.50
Rate for Payer: Hawaii Medical Service Association Commercial	$696,862.50
Rate for Payer: University Health Alliance Commercial	$10,400.00

simvastatin 20 mg Tab [KMC]

Facility

$19.68

Service Code	NDC 51079045520
Hospital Revenue Code	250
Min. Negotiated Rate	$8.27
Max. Negotiated Rate	$19.09
Rate for Payer: AlohaCare Medicaid	$9.84
Rate for Payer: AlohaCare Medicare	$8.27
Rate for Payer: Cash Price	$12.79
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$18.11
Rate for Payer: Devoted Health Medicare	$8.27
Rate for Payer: Hawaii Medical Service Association Medicare	$8.27
Rate for Payer: Hawaii Western Management Group Commercial	$18.70
Rate for Payer: Health Management Network Commercial	$16.73
Rate for Payer: Humana Medicare	$8.27
Rate for Payer: Kaiser Permanente Commercial	$17.71
Rate for Payer: Kaiser Permanente Medicaid	$10.04
Rate for Payer: Kaiser Permanente Medicare	$8.27
Rate for Payer: MDX Hawaii PPO	$19.09
Rate for Payer: Ohana Health Plan Medicaid	$8.27
Rate for Payer: Ohana Health Plan Medicare	$8.27
Rate for Payer: UnitedHealthcare Medicaid	$11.81
Rate for Payer: UnitedHealthcare Medicare	$8.27
Rate for Payer: University Health Alliance Commercial	$14.34

simvastatin 20 mg Tab [KMC]

Facility

$19.68

Service Code	NDC 51079045520
Hospital Revenue Code	250
Min. Negotiated Rate	$16.73
Max. Negotiated Rate	$19.09
Rate for Payer: Cash Price	$12.79
Rate for Payer: Health Management Network Commercial	$16.73
Rate for Payer: Kaiser Permanente Commercial	$17.71
Rate for Payer: MDX Hawaii PPO	$19.09

simvastatin 40 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 63739057310
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

simvastatin 40 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 63739057310
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

simvastatin 5 mg Tab [KMC]

Facility

$8.79

Service Code	NDC 16714068102
Hospital Revenue Code	250
Min. Negotiated Rate	$7.47
Max. Negotiated Rate	$8.53
Rate for Payer: Cash Price	$5.71
Rate for Payer: Health Management Network Commercial	$7.47
Rate for Payer: Kaiser Permanente Commercial	$7.91
Rate for Payer: MDX Hawaii PPO	$8.53

simvastatin 5 mg Tab [KMC]

Facility

$8.79

Service Code	NDC 16714068102
Hospital Revenue Code	250
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$8.53
Rate for Payer: AlohaCare Medicaid	$4.39
Rate for Payer: AlohaCare Medicare	$3.69
Rate for Payer: Cash Price	$5.71
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.09
Rate for Payer: Devoted Health Medicare	$3.69
Rate for Payer: Hawaii Medical Service Association Medicare	$3.69
Rate for Payer: Hawaii Western Management Group Commercial	$8.35
Rate for Payer: Health Management Network Commercial	$7.47
Rate for Payer: Humana Medicare	$3.69
Rate for Payer: Kaiser Permanente Commercial	$7.91
Rate for Payer: Kaiser Permanente Medicaid	$4.48
Rate for Payer: Kaiser Permanente Medicare	$3.69
Rate for Payer: MDX Hawaii PPO	$8.53
Rate for Payer: Ohana Health Plan Medicaid	$3.69
Rate for Payer: Ohana Health Plan Medicare	$3.69
Rate for Payer: UnitedHealthcare Medicaid	$5.27
Rate for Payer: UnitedHealthcare Medicare	$3.69
Rate for Payer: University Health Alliance Commercial	$6.41

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$115,594.65

Service Code	MSDRG 402
Min. Negotiated Rate	$115,594.65
Max. Negotiated Rate	$115,594.65
Rate for Payer: Hawaii Medical Service Association Commercial	$115,594.65

Know your out-of-pocket cost for care.

All Charges