Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

sodium zirconium cyclosilicate 5 gm packet [KMC]

Facility

$113.34

Service Code	NDC 00310110539
Hospital Revenue Code	250
Min. Negotiated Rate	$96.34
Max. Negotiated Rate	$109.94
Rate for Payer: Cash Price	$73.67
Rate for Payer: Health Management Network Commercial	$96.34
Rate for Payer: Kaiser Permanente Commercial	$102.01
Rate for Payer: MDX Hawaii PPO	$109.94

sofosbuvir-velpatasvir 400 mg-100 mg Tab [KMC]

Facility

$4,272.00

Service Code	NDC 61958220101
Hospital Revenue Code	250
Min. Negotiated Rate	$1,794.24
Max. Negotiated Rate	$4,143.84
Rate for Payer: AlohaCare Medicaid	$2,136.00
Rate for Payer: AlohaCare Medicare	$1,794.24
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3,930.24
Rate for Payer: Devoted Health Medicare	$1,794.24
Rate for Payer: Hawaii Medical Service Association Medicare	$1,794.24
Rate for Payer: Hawaii Western Management Group Commercial	$4,058.40
Rate for Payer: Health Management Network Commercial	$3,631.20
Rate for Payer: Humana Medicare	$1,794.24
Rate for Payer: Kaiser Permanente Commercial	$3,844.80
Rate for Payer: Kaiser Permanente Medicaid	$2,178.72
Rate for Payer: Kaiser Permanente Medicare	$1,794.24
Rate for Payer: MDX Hawaii PPO	$4,143.84
Rate for Payer: Ohana Health Plan Medicaid	$1,794.24
Rate for Payer: Ohana Health Plan Medicare	$1,794.24
Rate for Payer: UnitedHealthcare Medicaid	$2,563.20
Rate for Payer: UnitedHealthcare Medicare	$1,794.24
Rate for Payer: University Health Alliance Commercial	$3,113.86

sofosbuvir-velpatasvir 400 mg-100 mg Tab [KMC]

Facility

$4,272.00

Service Code	NDC 61958220101
Hospital Revenue Code	250
Min. Negotiated Rate	$3,631.20
Max. Negotiated Rate	$4,143.84
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Health Management Network Commercial	$3,631.20
Rate for Payer: Kaiser Permanente Commercial	$3,844.80
Rate for Payer: MDX Hawaii PPO	$4,143.84

SOFT TISSUE PROCEDURES WITH CC

Facility

$46,408.52

Service Code	MSDRG 501
Min. Negotiated Rate	$46,408.52
Max. Negotiated Rate	$46,408.52
Rate for Payer: Hawaii Medical Service Association Commercial	$46,408.52

SOFT TISSUE PROCEDURES WITH MCC

Facility

$46,408.52

Service Code	MSDRG 500
Min. Negotiated Rate	$46,408.52
Max. Negotiated Rate	$46,408.52
Rate for Payer: Hawaii Medical Service Association Commercial	$46,408.52

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$22,896.13

Service Code	MSDRG 502
Min. Negotiated Rate	$22,896.13
Max. Negotiated Rate	$22,896.13
Rate for Payer: Hawaii Medical Service Association Commercial	$22,896.13

solifenacin 10 mg Tab [KMC]

Facility

$55.51

Service Code	NDC 50228042830
Hospital Revenue Code	250
Min. Negotiated Rate	$23.31
Max. Negotiated Rate	$53.84
Rate for Payer: AlohaCare Medicaid	$27.75
Rate for Payer: AlohaCare Medicare	$23.31
Rate for Payer: Cash Price	$36.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$51.07
Rate for Payer: Devoted Health Medicare	$23.31
Rate for Payer: Hawaii Medical Service Association Medicare	$23.31
Rate for Payer: Hawaii Western Management Group Commercial	$52.73
Rate for Payer: Health Management Network Commercial	$47.18
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Kaiser Permanente Commercial	$49.96
Rate for Payer: Kaiser Permanente Medicaid	$28.31
Rate for Payer: Kaiser Permanente Medicare	$23.31
Rate for Payer: MDX Hawaii PPO	$53.84
Rate for Payer: Ohana Health Plan Medicaid	$23.31
Rate for Payer: Ohana Health Plan Medicare	$23.31
Rate for Payer: UnitedHealthcare Medicaid	$33.31
Rate for Payer: UnitedHealthcare Medicare	$23.31
Rate for Payer: University Health Alliance Commercial	$40.46

solifenacin 10 mg Tab [KMC]

Facility

$55.51

Service Code	NDC 50228042830
Hospital Revenue Code	250
Min. Negotiated Rate	$47.18
Max. Negotiated Rate	$53.84
Rate for Payer: Cash Price	$36.08
Rate for Payer: Health Management Network Commercial	$47.18
Rate for Payer: Kaiser Permanente Commercial	$49.96
Rate for Payer: MDX Hawaii PPO	$53.84

solifenacin 5 mg Tab [KMC]

Facility

$55.51

Service Code	NDC 50228042790
Hospital Revenue Code	250
Min. Negotiated Rate	$23.31
Max. Negotiated Rate	$53.84
Rate for Payer: AlohaCare Medicaid	$27.75
Rate for Payer: AlohaCare Medicare	$23.31
Rate for Payer: Cash Price	$36.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$51.07
Rate for Payer: Devoted Health Medicare	$23.31
Rate for Payer: Hawaii Medical Service Association Medicare	$23.31
Rate for Payer: Hawaii Western Management Group Commercial	$52.73
Rate for Payer: Health Management Network Commercial	$47.18
Rate for Payer: Humana Medicare	$23.31
Rate for Payer: Kaiser Permanente Commercial	$49.96
Rate for Payer: Kaiser Permanente Medicaid	$28.31
Rate for Payer: Kaiser Permanente Medicare	$23.31
Rate for Payer: MDX Hawaii PPO	$53.84
Rate for Payer: Ohana Health Plan Medicaid	$23.31
Rate for Payer: Ohana Health Plan Medicare	$23.31
Rate for Payer: UnitedHealthcare Medicaid	$33.31
Rate for Payer: UnitedHealthcare Medicare	$23.31
Rate for Payer: University Health Alliance Commercial	$40.46

solifenacin 5 mg Tab [KMC]

Facility

$55.51

Service Code	NDC 50228042790
Hospital Revenue Code	250
Min. Negotiated Rate	$47.18
Max. Negotiated Rate	$53.84
Rate for Payer: Cash Price	$36.08
Rate for Payer: Health Management Network Commercial	$47.18
Rate for Payer: Kaiser Permanente Commercial	$49.96
Rate for Payer: MDX Hawaii PPO	$53.84

sorbitol 70% Oral Liq 30 mL [KMC]

Facility

$0.30

Service Code	NDC 46287050030
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Management Network Commercial	$0.26
Rate for Payer: Kaiser Permanente Commercial	$0.27
Rate for Payer: MDX Hawaii PPO	$0.29

sorbitol 70% Oral Liq 30 mL [KMC]

Facility

$0.30

Service Code	NDC 46287050030
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.29
Rate for Payer: AlohaCare Medicaid	$0.15
Rate for Payer: AlohaCare Medicare	$0.13
Rate for Payer: Cash Price	$0.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.28
Rate for Payer: Devoted Health Medicare	$0.13
Rate for Payer: Hawaii Medical Service Association Medicare	$0.13
Rate for Payer: Hawaii Western Management Group Commercial	$0.29
Rate for Payer: Health Management Network Commercial	$0.26
Rate for Payer: Humana Medicare	$0.13
Rate for Payer: Kaiser Permanente Commercial	$0.27
Rate for Payer: Kaiser Permanente Medicaid	$0.15
Rate for Payer: Kaiser Permanente Medicare	$0.13
Rate for Payer: MDX Hawaii PPO	$0.29
Rate for Payer: Ohana Health Plan Medicaid	$0.13
Rate for Payer: Ohana Health Plan Medicare	$0.13
Rate for Payer: UnitedHealthcare Medicaid	$0.18
Rate for Payer: UnitedHealthcare Medicare	$0.13
Rate for Payer: University Health Alliance Commercial	$0.22

sotalol 120 mg Tab [KMC]

Facility

$12.53

Service Code	NDC 69584084210
Hospital Revenue Code	250
Min. Negotiated Rate	$5.26
Max. Negotiated Rate	$12.15
Rate for Payer: AlohaCare Medicaid	$6.26
Rate for Payer: AlohaCare Medicare	$5.26
Rate for Payer: Cash Price	$8.14
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.53
Rate for Payer: Devoted Health Medicare	$5.26
Rate for Payer: Hawaii Medical Service Association Medicare	$5.26
Rate for Payer: Hawaii Western Management Group Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$10.65
Rate for Payer: Humana Medicare	$5.26
Rate for Payer: Kaiser Permanente Commercial	$11.28
Rate for Payer: Kaiser Permanente Medicaid	$6.39
Rate for Payer: Kaiser Permanente Medicare	$5.26
Rate for Payer: MDX Hawaii PPO	$12.15
Rate for Payer: Ohana Health Plan Medicaid	$5.26
Rate for Payer: Ohana Health Plan Medicare	$5.26
Rate for Payer: UnitedHealthcare Medicaid	$7.52
Rate for Payer: UnitedHealthcare Medicare	$5.26
Rate for Payer: University Health Alliance Commercial	$9.13

sotalol 120 mg Tab [KMC]

Facility

$12.53

Service Code	NDC 69584084210
Hospital Revenue Code	250
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$12.15
Rate for Payer: Cash Price	$8.14
Rate for Payer: Health Management Network Commercial	$10.65
Rate for Payer: Kaiser Permanente Commercial	$11.28
Rate for Payer: MDX Hawaii PPO	$12.15

Spacer [KMC]

Facility

$80.40

Service Code	NDC 42135010000
Hospital Revenue Code	250
Min. Negotiated Rate	$68.34
Max. Negotiated Rate	$77.99
Rate for Payer: Cash Price	$52.26
Rate for Payer: Health Management Network Commercial	$68.34
Rate for Payer: Kaiser Permanente Commercial	$72.36
Rate for Payer: MDX Hawaii PPO	$77.99

Spacer [KMC]

Facility

$80.40

Service Code	NDC 42135010000
Hospital Revenue Code	250
Min. Negotiated Rate	$33.77
Max. Negotiated Rate	$77.99
Rate for Payer: AlohaCare Medicaid	$40.20
Rate for Payer: AlohaCare Medicare	$33.77
Rate for Payer: Cash Price	$52.26
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$73.97
Rate for Payer: Devoted Health Medicare	$33.77
Rate for Payer: Hawaii Medical Service Association Medicare	$33.77
Rate for Payer: Hawaii Western Management Group Commercial	$76.38
Rate for Payer: Health Management Network Commercial	$68.34
Rate for Payer: Humana Medicare	$33.77
Rate for Payer: Kaiser Permanente Commercial	$72.36
Rate for Payer: Kaiser Permanente Medicaid	$41.00
Rate for Payer: Kaiser Permanente Medicare	$33.77
Rate for Payer: MDX Hawaii PPO	$77.99
Rate for Payer: Ohana Health Plan Medicaid	$33.77
Rate for Payer: Ohana Health Plan Medicare	$33.77
Rate for Payer: UnitedHealthcare Medicaid	$48.24
Rate for Payer: UnitedHealthcare Medicare	$33.77
Rate for Payer: University Health Alliance Commercial	$58.60

SPEECH EVALUATION Speech

Facility

$396.00

Service Code	HCPCS 92506 GN
Hospital Charge Code	431925060
Hospital Revenue Code	444
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$384.12
Rate for Payer: Cash Price	$257.40
Rate for Payer: Health Management Network Commercial	$336.60
Rate for Payer: Kaiser Permanente Commercial	$356.40
Rate for Payer: MDX Hawaii PPO	$384.12

SPEECH EVALUATION Speech

Facility

$396.00

Service Code	HCPCS 92506 GN
Hospital Charge Code	431925060
Hospital Revenue Code	444
Min. Negotiated Rate	$166.32
Max. Negotiated Rate	$384.12
Rate for Payer: AlohaCare Medicaid	$198.00
Rate for Payer: AlohaCare Medicare	$166.32
Rate for Payer: Cash Price	$257.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$364.32
Rate for Payer: Devoted Health Medicare	$166.32
Rate for Payer: Hawaii Medical Service Association Medicare	$166.32
Rate for Payer: Hawaii Western Management Group Commercial	$376.20
Rate for Payer: Health Management Network Commercial	$336.60
Rate for Payer: Humana Medicare	$166.32
Rate for Payer: Kaiser Permanente Commercial	$356.40
Rate for Payer: Kaiser Permanente Medicaid	$201.96
Rate for Payer: Kaiser Permanente Medicare	$166.32
Rate for Payer: MDX Hawaii PPO	$384.12
Rate for Payer: Ohana Health Plan Medicaid	$166.32
Rate for Payer: Ohana Health Plan Medicare	$166.32
Rate for Payer: UnitedHealthcare Medicare	$166.32
Rate for Payer: University Health Alliance Commercial	$288.64

SPEECH & HEARING EVALUATION

Professional

Both

$377.00

Service Code	HCPCS 92506
Hospital Revenue Code	440
Min. Negotiated Rate	$56.09
Max. Negotiated Rate	$320.45
Rate for Payer: Cash Price	$245.05
Rate for Payer: Cash Price	$245.05
Rate for Payer: Hawaii Western Management Group Commercial	$56.09
Rate for Payer: Health Management Network Commercial	$320.45

SPEECH LANG CURRENT STATUS

Professional

Both

$0.01

Service Code	HCPCS G9174
Hospital Revenue Code	440
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

SPEECH LANG CURR STATUS Speech

Facility

$1.00

Service Code	HCPCS G9174 GN
Hospital Charge Code	432G91740
Hospital Revenue Code	440
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

SPEECH LANG CURR STATUS Speech

Facility

$1.00

Service Code	HCPCS G9174 GN
Hospital Charge Code	432G91740
Hospital Revenue Code	440
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

SPEECH LANG D/C STATUS

Professional

Both

$0.01

Service Code	HCPCS G9176
Hospital Revenue Code	440
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

SPEECH LANG D/C STATUS Speech

Facility

$1.00

Service Code	HCPCS G9176 GN
Hospital Charge Code	432G91760
Hospital Revenue Code	440
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

SPEECH LANG D/C STATUS Speech

Facility

$1.00

Service Code	HCPCS G9176 GN
Hospital Charge Code	432G91760
Hospital Revenue Code	440
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

Know your out-of-pocket cost for care.

All Charges