Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

spironolactone 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 72603013401
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

spironolactone 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 72603013401
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

SPLENIC PROCEDURES WITH CC

Facility

$43,730.19

Service Code	MSDRG 800
Min. Negotiated Rate	$43,730.19
Max. Negotiated Rate	$43,730.19
Rate for Payer: Hawaii Medical Service Association Commercial	$43,730.19

SPLENIC PROCEDURES WITH MCC

Facility

$43,730.19

Service Code	MSDRG 799
Min. Negotiated Rate	$43,730.19
Max. Negotiated Rate	$43,730.19
Rate for Payer: Hawaii Medical Service Association Commercial	$43,730.19

SPLENIC PROCEDURES WITHOUT CC/MCC

Facility

$43,730.19

Service Code	MSDRG 801
Min. Negotiated Rate	$43,730.19
Max. Negotiated Rate	$43,730.19
Rate for Payer: Hawaii Medical Service Association Commercial	$43,730.19

SPLINT HAND OR FINGER Charge

Facility

$286.00

Service Code	HCPCS 29280
Hospital Charge Code	440292800
Hospital Revenue Code	450
Min. Negotiated Rate	$243.10
Max. Negotiated Rate	$277.42
Rate for Payer: Cash Price	$185.90
Rate for Payer: Health Management Network Commercial	$243.10
Rate for Payer: Kaiser Permanente Commercial	$257.40
Rate for Payer: MDX Hawaii PPO	$277.42

SPLINT HAND OR FINGER Charge

Facility

$286.00

Service Code	HCPCS 29280
Hospital Charge Code	440292800
Hospital Revenue Code	450
Min. Negotiated Rate	$120.12
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$143.00
Rate for Payer: AlohaCare Medicare	$120.12
Rate for Payer: Cash Price	$185.90
Rate for Payer: Cash Price	$185.90
Rate for Payer: Cash Price	$185.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$263.12
Rate for Payer: Devoted Health Medicare	$120.12
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	$120.12
Rate for Payer: Hawaii Western Management Group Commercial	$271.70
Rate for Payer: Health Management Network Commercial	$243.10
Rate for Payer: Humana Medicare	$120.12
Rate for Payer: Kaiser Permanente Commercial	$257.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$120.12
Rate for Payer: MDX Hawaii PPO	$277.42
Rate for Payer: Ohana Health Plan Medicaid	$120.12
Rate for Payer: Ohana Health Plan Medicare	$120.12
Rate for Payer: UnitedHealthcare Medicare	$120.12
Rate for Payer: University Health Alliance Commercial	$208.47

SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ

Professional

Both

$325.00

Service Code	HCPCS 94010
Hospital Revenue Code	410
Min. Negotiated Rate	$30.13
Max. Negotiated Rate	$276.25
Rate for Payer: AlohaCare Medicaid	$30.13
Rate for Payer: AlohaCare Medicare	$32.65
Rate for Payer: Cash Price	$211.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Devoted Health Medicare	$32.65
Rate for Payer: Hawaii Medical Service Association Medicare	$32.65
Rate for Payer: Hawaii Western Management Group Commercial	$33.23
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Kaiser Permanente Commercial	$39.18
Rate for Payer: Kaiser Permanente Medicaid	$39.18
Rate for Payer: Kaiser Permanente Medicare	$39.18
Rate for Payer: Ohana Health Plan Medicaid	$30.13
Rate for Payer: Ohana Health Plan Medicare	$32.65
Rate for Payer: UnitedHealthcare Medicaid	$30.13
Rate for Payer: UnitedHealthcare Medicare	$32.65

SPO2 SENSOR NEO-ADULT

Facility

$42.00

Hospital Charge Code	8410
Hospital Revenue Code	270
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$27.30
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: MDX Hawaii PPO	$40.74

SPO2 SENSOR NEO-ADULT

Facility

$42.00

Hospital Charge Code	8410
Hospital Revenue Code	270
Min. Negotiated Rate	$17.64
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$21.00
Rate for Payer: AlohaCare Medicare	$17.64
Rate for Payer: Cash Price	$27.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$38.64
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$17.64
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$17.64
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$17.64
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$17.64
Rate for Payer: Ohana Health Plan Medicare	$17.64
Rate for Payer: UnitedHealthcare Medicare	$17.64
Rate for Payer: University Health Alliance Commercial	$30.61

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC

Facility

$24,910.80

Service Code	MSDRG 537
Min. Negotiated Rate	$24,910.80
Max. Negotiated Rate	$24,910.80
Rate for Payer: Hawaii Medical Service Association Commercial	$24,910.80

SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC

Facility

$24,910.80

Service Code	MSDRG 538
Min. Negotiated Rate	$24,910.80
Max. Negotiated Rate	$24,910.80
Rate for Payer: Hawaii Medical Service Association Commercial	$24,910.80

Standardized Cognitive Eval Charge

Facility

$485.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	431961250
Hospital Revenue Code	440
Min. Negotiated Rate	$412.25
Max. Negotiated Rate	$470.45
Rate for Payer: Cash Price	$315.25
Rate for Payer: Health Management Network Commercial	$412.25
Rate for Payer: Kaiser Permanente Commercial	$436.50
Rate for Payer: MDX Hawaii PPO	$470.45

Standardized Cognitive Eval Charge

Facility

$485.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	431961250
Hospital Revenue Code	440
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$470.45
Rate for Payer: AlohaCare Medicaid	$242.50
Rate for Payer: AlohaCare Medicare	$203.70
Rate for Payer: Cash Price	$315.25
Rate for Payer: Cash Price	$315.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$446.20
Rate for Payer: Devoted Health Medicare	$203.70
Rate for Payer: Hawaii Medical Service Association Medicare	$203.70
Rate for Payer: Hawaii Western Management Group Commercial	$460.75
Rate for Payer: Health Management Network Commercial	$412.25
Rate for Payer: Humana Medicare	$203.70
Rate for Payer: Kaiser Permanente Commercial	$436.50
Rate for Payer: Kaiser Permanente Medicaid	$247.35
Rate for Payer: Kaiser Permanente Medicare	$203.70
Rate for Payer: MDX Hawaii PPO	$470.45
Rate for Payer: Ohana Health Plan Medicaid	$203.70
Rate for Payer: Ohana Health Plan Medicare	$203.70
Rate for Payer: UnitedHealthcare Medicaid	$41.65
Rate for Payer: UnitedHealthcare Medicare	$203.70
Rate for Payer: University Health Alliance Commercial	$353.52

STANDARDIZED COGNITIVE PERFORMANCE TESTING

Professional

Both

$461.00

Service Code	HCPCS 96125
Hospital Revenue Code	440
Min. Negotiated Rate	$107.81
Max. Negotiated Rate	$391.85
Rate for Payer: AlohaCare Medicaid	$107.81
Rate for Payer: AlohaCare Medicare	$108.44
Rate for Payer: Cash Price	$299.65
Rate for Payer: Cash Price	$299.65
Rate for Payer: Devoted Health Medicare	$108.44
Rate for Payer: Hawaii Medical Service Association Medicare	$108.44
Rate for Payer: Hawaii Western Management Group Commercial	$121.99
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Kaiser Permanente Commercial	$130.13
Rate for Payer: Kaiser Permanente Medicaid	$130.13
Rate for Payer: Kaiser Permanente Medicare	$130.13
Rate for Payer: Ohana Health Plan Medicaid	$107.81
Rate for Payer: Ohana Health Plan Medicare	$108.44
Rate for Payer: UnitedHealthcare Medicaid	$107.81
Rate for Payer: UnitedHealthcare Medicare	$108.44

Staph Sensitivity DLS

Facility

$150.00

Service Code	HCPCS 87186
Hospital Charge Code	422871865
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$145.50
Rate for Payer: AlohaCare Medicaid	$75.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$138.00
Rate for Payer: Devoted Health Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$22.35

Staph Sensitivity DLS

Facility

$150.00

Service Code	HCPCS 87186
Hospital Charge Code	422871865
Hospital Revenue Code	306
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$135.00
Rate for Payer: MDX Hawaii PPO	$145.50

STAT PADS2 ADULT

Facility

$3.00

Hospital Charge Code	8476
Hospital Revenue Code	270
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

STAT PADS2 ADULT

Facility

$3.00

Hospital Charge Code	8476
Hospital Revenue Code	270
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

STAT PADS2 PEDS

Facility

$19.00

Hospital Charge Code	8477
Hospital Revenue Code	270
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$12.35
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

STAT PADS2 PEDS

Facility

$19.00

Hospital Charge Code	8477
Hospital Revenue Code	270
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$7.98
Rate for Payer: Cash Price	$12.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$17.48
Rate for Payer: Devoted Health Medicare	$7.98
Rate for Payer: Hawaii Medical Service Association Medicare	$7.98
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$7.98
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$7.98
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$7.98
Rate for Payer: Ohana Health Plan Medicare	$7.98
Rate for Payer: UnitedHealthcare Medicare	$7.98
Rate for Payer: University Health Alliance Commercial	$13.85

STERILE BOWL

Facility

$3.00

Hospital Charge Code	8283
Hospital Revenue Code	270
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

STERILE BOWL

Facility

$3.00

Hospital Charge Code	8283
Hospital Revenue Code	270
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

STERILE GAUZE 4X4 PK/10

Facility

$37.00

Hospital Charge Code	8285
Hospital Revenue Code	272
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$35.89
Rate for Payer: AlohaCare Medicaid	$18.50
Rate for Payer: AlohaCare Medicare	$15.54
Rate for Payer: Cash Price	$24.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.04
Rate for Payer: Devoted Health Medicare	$15.54
Rate for Payer: Hawaii Medical Service Association Medicare	$15.54
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Humana Medicare	$15.54
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: Kaiser Permanente Medicare	$15.54
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: Ohana Health Plan Medicaid	$15.54
Rate for Payer: Ohana Health Plan Medicare	$15.54
Rate for Payer: UnitedHealthcare Medicare	$15.54
Rate for Payer: University Health Alliance Commercial	$26.97

STERILE GAUZE 4X4 PK/10

Facility

$37.00

Hospital Charge Code	8285
Hospital Revenue Code	272
Min. Negotiated Rate	$31.45
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$24.05
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$33.30
Rate for Payer: MDX Hawaii PPO	$35.89

Know your out-of-pocket cost for care.

All Charges