Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

SINGLE USE LARYNGEL MASK #1

Facility

$93.00

Hospital Charge Code	8432
Hospital Revenue Code	270
Min. Negotiated Rate	$39.06
Max. Negotiated Rate	$90.21
Rate for Payer: AlohaCare Medicaid	$46.50
Rate for Payer: AlohaCare Medicare	$39.06
Rate for Payer: Cash Price	$60.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$85.56
Rate for Payer: Devoted Health Medicare	$39.06
Rate for Payer: Hawaii Medical Service Association Medicare	$39.06
Rate for Payer: Hawaii Western Management Group Commercial	$88.35
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Humana Medicare	$39.06
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: Kaiser Permanente Medicare	$39.06
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: Ohana Health Plan Medicaid	$39.06
Rate for Payer: Ohana Health Plan Medicare	$39.06
Rate for Payer: UnitedHealthcare Medicare	$39.06
Rate for Payer: University Health Alliance Commercial	$67.79

SINGLE USE LARYNGEL MASK #1

Facility

$93.00

Hospital Charge Code	8432
Hospital Revenue Code	270
Min. Negotiated Rate	$79.05
Max. Negotiated Rate	$90.21
Rate for Payer: Cash Price	$60.45
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: MDX Hawaii PPO	$90.21

SINGLE USE LARYNGEL MASK #2

Facility

$67.00

Hospital Charge Code	8433
Hospital Revenue Code	270
Min. Negotiated Rate	$28.14
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$28.14
Rate for Payer: Cash Price	$43.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$61.64
Rate for Payer: Devoted Health Medicare	$28.14
Rate for Payer: Hawaii Medical Service Association Medicare	$28.14
Rate for Payer: Hawaii Western Management Group Commercial	$63.65
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$28.14
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$28.14
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$28.14
Rate for Payer: Ohana Health Plan Medicare	$28.14
Rate for Payer: UnitedHealthcare Medicare	$28.14
Rate for Payer: University Health Alliance Commercial	$48.84

SINGLE USE LARYNGEL MASK #2

Facility

$67.00

Hospital Charge Code	8433
Hospital Revenue Code	270
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

SINGLE USE LARYNGEL MASK #4

Facility

$7.00

Hospital Charge Code	8270
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

SINGLE USE LARYNGEL MASK #4

Facility

$7.00

Hospital Charge Code	8270
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

SINGLE USE LARYNGEL MASK #5

Facility

$7.00

Hospital Charge Code	8271
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

SINGLE USE LARYNGEL MASK #5

Facility

$7.00

Hospital Charge Code	8271
Hospital Revenue Code	270
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$2.94
Rate for Payer: Cash Price	$4.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.44
Rate for Payer: Devoted Health Medicare	$2.94
Rate for Payer: Hawaii Medical Service Association Medicare	$2.94
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$2.94
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$2.94
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$2.94
Rate for Payer: Ohana Health Plan Medicare	$2.94
Rate for Payer: UnitedHealthcare Medicare	$2.94
Rate for Payer: University Health Alliance Commercial	$5.10

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$25,882.58

Service Code	MSDRG 135
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$25,882.58

Service Code	MSDRG 136
Min. Negotiated Rate	$25,882.58
Max. Negotiated Rate	$25,882.58
Rate for Payer: Hawaii Medical Service Association Commercial	$25,882.58

SINUSES PARANASAL UNDER 3 VWS

Facility

$369.00

Service Code	HCPCS 70210
Hospital Charge Code	424702100
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

SINUSES PARANASAL UNDER 3 VWS

Facility

$369.00

Service Code	HCPCS 70210
Hospital Charge Code	424702100
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
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	$20.40
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	$20.40
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$62.81

SINUSES PARANASL COMP MIN 3 VW

Facility

$479.00

Service Code	HCPCS 70220
Hospital Charge Code	424702200
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$464.63
Rate for Payer: AlohaCare Medicaid	$239.50
Rate for Payer: AlohaCare Medicare	$201.18
Rate for Payer: Cash Price	$311.35
Rate for Payer: Cash Price	$311.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$440.68
Rate for Payer: Devoted Health Medicare	$201.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.96
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$201.18
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$407.15
Rate for Payer: Humana Medicare	$201.18
Rate for Payer: Kaiser Permanente Commercial	$431.10
Rate for Payer: Kaiser Permanente Medicaid	$244.29
Rate for Payer: Kaiser Permanente Medicare	$201.18
Rate for Payer: MDX Hawaii PPO	$464.63
Rate for Payer: Ohana Health Plan Medicaid	$201.18
Rate for Payer: Ohana Health Plan Medicare	$201.18
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: UnitedHealthcare Medicare	$201.18
Rate for Payer: University Health Alliance Commercial	$82.68

SINUSES PARANASL COMP MIN 3 VW

Facility

$479.00

Service Code	HCPCS 70220
Hospital Charge Code	424702200
Hospital Revenue Code	320
Min. Negotiated Rate	$407.15
Max. Negotiated Rate	$464.63
Rate for Payer: Cash Price	$311.35
Rate for Payer: Health Management Network Commercial	$407.15
Rate for Payer: Kaiser Permanente Commercial	$431.10
Rate for Payer: MDX Hawaii PPO	$464.63

sirolimus 1 mg Tab [KMC]

Facility

$67.99

Service Code	HCPCS J7520
Hospital Revenue Code	636
Min. Negotiated Rate	$57.79
Max. Negotiated Rate	$65.95
Rate for Payer: Cash Price	$44.19
Rate for Payer: Health Management Network Commercial	$57.79
Rate for Payer: Kaiser Permanente Commercial	$61.19
Rate for Payer: MDX Hawaii PPO	$65.95

sirolimus 1 mg Tab [KMC]

Facility

$67.99

Service Code	HCPCS J7520
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$65.95
Rate for Payer: AlohaCare Medicaid	$33.99
Rate for Payer: AlohaCare Medicare	$28.56
Rate for Payer: Cash Price	$44.19
Rate for Payer: Cash Price	$44.19
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$62.55
Rate for Payer: Devoted Health Medicare	$28.56
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Medicare	$28.56
Rate for Payer: Hawaii Western Management Group Commercial	$64.59
Rate for Payer: Health Management Network Commercial	$57.79
Rate for Payer: Humana Medicare	$28.56
Rate for Payer: Kaiser Permanente Commercial	$61.19
Rate for Payer: Kaiser Permanente Medicaid	$34.67
Rate for Payer: Kaiser Permanente Medicare	$28.56
Rate for Payer: MDX Hawaii PPO	$65.95
Rate for Payer: Ohana Health Plan Medicaid	$28.56
Rate for Payer: Ohana Health Plan Medicare	$28.56
Rate for Payer: UnitedHealthcare Medicaid	$40.79
Rate for Payer: UnitedHealthcare Medicare	$28.56
Rate for Payer: University Health Alliance Commercial	$49.56

sitaGLIPtin 100 mg Tab [KMC]

Facility

$41.32

Service Code	NDC 00006027731
Hospital Revenue Code	250
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$40.08
Rate for Payer: Cash Price	$26.86
Rate for Payer: Health Management Network Commercial	$35.12
Rate for Payer: Kaiser Permanente Commercial	$37.19
Rate for Payer: MDX Hawaii PPO	$40.08

sitaGLIPtin 100 mg Tab [KMC]

Facility

$41.32

Service Code	NDC 00006027731
Hospital Revenue Code	250
Min. Negotiated Rate	$17.35
Max. Negotiated Rate	$40.08
Rate for Payer: AlohaCare Medicaid	$20.66
Rate for Payer: AlohaCare Medicare	$17.35
Rate for Payer: Cash Price	$26.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$38.01
Rate for Payer: Devoted Health Medicare	$17.35
Rate for Payer: Hawaii Medical Service Association Medicare	$17.35
Rate for Payer: Hawaii Western Management Group Commercial	$39.25
Rate for Payer: Health Management Network Commercial	$35.12
Rate for Payer: Humana Medicare	$17.35
Rate for Payer: Kaiser Permanente Commercial	$37.19
Rate for Payer: Kaiser Permanente Medicaid	$21.07
Rate for Payer: Kaiser Permanente Medicare	$17.35
Rate for Payer: MDX Hawaii PPO	$40.08
Rate for Payer: Ohana Health Plan Medicaid	$17.35
Rate for Payer: Ohana Health Plan Medicare	$17.35
Rate for Payer: UnitedHealthcare Medicaid	$24.79
Rate for Payer: UnitedHealthcare Medicare	$17.35
Rate for Payer: University Health Alliance Commercial	$30.12

sitaGLIPtin 50 mg Tab [KMC]

Facility

$45.41

Service Code	NDC 00006011231
Hospital Revenue Code	250
Min. Negotiated Rate	$19.07
Max. Negotiated Rate	$44.05
Rate for Payer: AlohaCare Medicaid	$22.70
Rate for Payer: AlohaCare Medicare	$19.07
Rate for Payer: Cash Price	$29.52
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$41.78
Rate for Payer: Devoted Health Medicare	$19.07
Rate for Payer: Hawaii Medical Service Association Medicare	$19.07
Rate for Payer: Hawaii Western Management Group Commercial	$43.14
Rate for Payer: Health Management Network Commercial	$38.60
Rate for Payer: Humana Medicare	$19.07
Rate for Payer: Kaiser Permanente Commercial	$40.87
Rate for Payer: Kaiser Permanente Medicaid	$23.16
Rate for Payer: Kaiser Permanente Medicare	$19.07
Rate for Payer: MDX Hawaii PPO	$44.05
Rate for Payer: Ohana Health Plan Medicaid	$19.07
Rate for Payer: Ohana Health Plan Medicare	$19.07
Rate for Payer: UnitedHealthcare Medicaid	$27.25
Rate for Payer: UnitedHealthcare Medicare	$19.07
Rate for Payer: University Health Alliance Commercial	$33.10

sitaGLIPtin 50 mg Tab [KMC]

Facility

$45.41

Service Code	NDC 00006011231
Hospital Revenue Code	250
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$44.05
Rate for Payer: Cash Price	$29.52
Rate for Payer: Health Management Network Commercial	$38.60
Rate for Payer: Kaiser Permanente Commercial	$40.87
Rate for Payer: MDX Hawaii PPO	$44.05

SKIN DEBRIDEMENT WITH CC

Facility

$57,951.39

Service Code	MSDRG 571
Min. Negotiated Rate	$57,951.39
Max. Negotiated Rate	$57,951.39
Rate for Payer: Hawaii Medical Service Association Commercial	$57,951.39

SKIN DEBRIDEMENT WITH MCC

Facility

$60,795.63

Service Code	MSDRG 570
Min. Negotiated Rate	$60,795.63
Max. Negotiated Rate	$60,795.63
Rate for Payer: Hawaii Medical Service Association Commercial	$60,795.63

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$29,983.03

Service Code	MSDRG 572
Min. Negotiated Rate	$29,983.03
Max. Negotiated Rate	$29,983.03
Rate for Payer: Hawaii Medical Service Association Commercial	$29,983.03

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$59,894.95

Service Code	MSDRG 577
Min. Negotiated Rate	$59,894.95
Max. Negotiated Rate	$59,894.95
Rate for Payer: Hawaii Medical Service Association Commercial	$59,894.95

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$59,894.95

Service Code	MSDRG 576
Min. Negotiated Rate	$59,894.95
Max. Negotiated Rate	$59,894.95
Rate for Payer: Hawaii Medical Service Association Commercial	$59,894.95

Know your out-of-pocket cost for care.

All Charges