Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

STERILE H2O INSULATION 300ML

Facility

$4.00

Hospital Charge Code	8287
Hospital Revenue Code	272
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

STERILE H2O INSULATION 300ML

Facility

$4.00

Hospital Charge Code	8287
Hospital Revenue Code	272
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

sterile water for injection 50 mL vial [KMC]

Facility

$0.28

Service Code	HCPCS A4217
Hospital Revenue Code	637
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.43
Rate for Payer: AlohaCare Medicaid	$0.14
Rate for Payer: AlohaCare Medicare	$0.12
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.26
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Hawaii Medical Service Association Medicare	$0.12
Rate for Payer: Hawaii Western Management Group Commercial	$0.27
Rate for Payer: Health Management Network Commercial	$0.24
Rate for Payer: Humana Medicare	$0.12
Rate for Payer: Kaiser Permanente Commercial	$0.25
Rate for Payer: Kaiser Permanente Medicaid	$0.14
Rate for Payer: Kaiser Permanente Medicare	$0.12
Rate for Payer: MDX Hawaii PPO	$0.27
Rate for Payer: Ohana Health Plan Medicaid	$0.12
Rate for Payer: Ohana Health Plan Medicare	$0.12
Rate for Payer: UnitedHealthcare Medicaid	$2.43
Rate for Payer: UnitedHealthcare Medicare	$0.12
Rate for Payer: University Health Alliance Commercial	$0.20

sterile water for injection 50 mL vial [KMC]

Facility

$0.28

Service Code	HCPCS A4217
Hospital Revenue Code	637
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Management Network Commercial	$0.24
Rate for Payer: Kaiser Permanente Commercial	$0.25
Rate for Payer: MDX Hawaii PPO	$0.27

sterile water Inj Sol [KMC]

Facility

$0.45

Service Code	HCPCS A4217
Hospital Revenue Code	637
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Management Network Commercial	$0.38
Rate for Payer: Kaiser Permanente Commercial	$0.41
Rate for Payer: MDX Hawaii PPO	$0.44

sterile water Inj Sol [KMC]

Facility

$0.45

Service Code	HCPCS A4217
Hospital Revenue Code	637
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$2.43
Rate for Payer: AlohaCare Medicaid	$0.23
Rate for Payer: AlohaCare Medicare	$0.19
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cash Price	$0.29
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.41
Rate for Payer: Devoted Health Medicare	$0.19
Rate for Payer: Hawaii Medical Service Association Medicare	$0.19
Rate for Payer: Hawaii Western Management Group Commercial	$0.43
Rate for Payer: Health Management Network Commercial	$0.38
Rate for Payer: Humana Medicare	$0.19
Rate for Payer: Kaiser Permanente Commercial	$0.41
Rate for Payer: Kaiser Permanente Medicaid	$0.23
Rate for Payer: Kaiser Permanente Medicare	$0.19
Rate for Payer: MDX Hawaii PPO	$0.44
Rate for Payer: Ohana Health Plan Medicaid	$0.19
Rate for Payer: Ohana Health Plan Medicare	$0.19
Rate for Payer: UnitedHealthcare Medicaid	$2.43
Rate for Payer: UnitedHealthcare Medicare	$0.19
Rate for Payer: University Health Alliance Commercial	$0.33

sterile water Irr Sol 1000 mL [KMC]

Facility

$0.01

Service Code	HCPCS A4217
Hospital Revenue Code	637
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
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01

sterile water Irr Sol 1000 mL [KMC]

Facility

$0.01

Service Code	HCPCS A4217
Hospital Revenue Code	637
Max. Negotiated Rate	$2.43
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.01
Rate for Payer: Devoted Health Medicare	$0.00
Rate for Payer: Hawaii Medical Service Association Medicare	$0.00
Rate for Payer: Hawaii Western Management Group Commercial	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Humana Medicare	$0.00
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: Kaiser Permanente Medicaid	$0.01
Rate for Payer: Kaiser Permanente Medicare	$0.00
Rate for Payer: MDX Hawaii PPO	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$0.00
Rate for Payer: Ohana Health Plan Medicare	$0.00
Rate for Payer: UnitedHealthcare Medicaid	$2.43
Rate for Payer: UnitedHealthcare Medicare	$0.00
Rate for Payer: University Health Alliance Commercial	$0.01

sterile water Irr Sol 250 mL [KMC]

Facility

$0.18

Service Code	HCPCS A4217
Hospital Revenue Code	637
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Management Network Commercial	$0.15
Rate for Payer: Kaiser Permanente Commercial	$0.16
Rate for Payer: MDX Hawaii PPO	$0.17

sterile water Irr Sol 250 mL [KMC]

Facility

$0.18

Service Code	HCPCS A4217
Hospital Revenue Code	637
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$2.43
Rate for Payer: AlohaCare Medicaid	$0.09
Rate for Payer: AlohaCare Medicare	$0.08
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.17
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Hawaii Medical Service Association Medicare	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$0.17
Rate for Payer: Health Management Network Commercial	$0.15
Rate for Payer: Humana Medicare	$0.08
Rate for Payer: Kaiser Permanente Commercial	$0.16
Rate for Payer: Kaiser Permanente Medicaid	$0.09
Rate for Payer: Kaiser Permanente Medicare	$0.08
Rate for Payer: MDX Hawaii PPO	$0.17
Rate for Payer: Ohana Health Plan Medicaid	$0.08
Rate for Payer: Ohana Health Plan Medicare	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$2.43
Rate for Payer: UnitedHealthcare Medicare	$0.08
Rate for Payer: University Health Alliance Commercial	$0.13

STERI STRIP 1/2"

Facility

$6.00

Hospital Charge Code	8280
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

STERI STRIP 1/2"

Facility

$6.00

Hospital Charge Code	8280
Hospital Revenue Code	272
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

STERI STRIP 1/4"

Facility

$6.00

Hospital Charge Code	8281
Hospital Revenue Code	272
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

STERI STRIP 1/4"

Facility

$6.00

Hospital Charge Code	8281
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

STERI STRIP 1/8"

Facility

$75.00

Hospital Charge Code	8282
Hospital Revenue Code	272
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

STERI STRIP 1/8"

Facility

$75.00

Hospital Charge Code	8282
Hospital Revenue Code	272
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$72.75
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$48.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$69.00
Rate for Payer: Devoted Health Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$54.67

STERNOCLAVICULAR JT MIN 3 VWS

Facility

$431.00

Service Code	HCPCS 71130
Hospital Charge Code	424711300
Hospital Revenue Code	320
Min. Negotiated Rate	$23.21
Max. Negotiated Rate	$418.07
Rate for Payer: AlohaCare Medicaid	$215.50
Rate for Payer: AlohaCare Medicare	$181.02
Rate for Payer: Cash Price	$280.15
Rate for Payer: Cash Price	$280.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$396.52
Rate for Payer: Devoted Health Medicare	$181.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$23.21
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$181.02
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Humana Medicare	$181.02
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: Kaiser Permanente Medicaid	$219.81
Rate for Payer: Kaiser Permanente Medicare	$181.02
Rate for Payer: MDX Hawaii PPO	$418.07
Rate for Payer: Ohana Health Plan Medicaid	$181.02
Rate for Payer: Ohana Health Plan Medicare	$181.02
Rate for Payer: UnitedHealthcare Medicaid	$23.21
Rate for Payer: UnitedHealthcare Medicare	$181.02
Rate for Payer: University Health Alliance Commercial	$76.85

STERNOCLAVICULAR JT MIN 3 VWS

Facility

$431.00

Service Code	HCPCS 71130
Hospital Charge Code	424711300
Hospital Revenue Code	320
Min. Negotiated Rate	$366.35
Max. Negotiated Rate	$418.07
Rate for Payer: Cash Price	$280.15
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: MDX Hawaii PPO	$418.07

STERNUM 2 VWS

Facility

$377.00

Service Code	HCPCS 71120
Hospital Charge Code	424711200
Hospital Revenue Code	320
Min. Negotiated Rate	$21.34
Max. Negotiated Rate	$365.69
Rate for Payer: AlohaCare Medicaid	$188.50
Rate for Payer: AlohaCare Medicare	$158.34
Rate for Payer: Cash Price	$245.05
Rate for Payer: Cash Price	$245.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$346.84
Rate for Payer: Devoted Health Medicare	$158.34
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$21.34
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$158.34
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: Humana Medicare	$158.34
Rate for Payer: Kaiser Permanente Commercial	$339.30
Rate for Payer: Kaiser Permanente Medicaid	$192.27
Rate for Payer: Kaiser Permanente Medicare	$158.34
Rate for Payer: MDX Hawaii PPO	$365.69
Rate for Payer: Ohana Health Plan Medicaid	$158.34
Rate for Payer: Ohana Health Plan Medicare	$158.34
Rate for Payer: UnitedHealthcare Medicaid	$21.34
Rate for Payer: UnitedHealthcare Medicare	$158.34
Rate for Payer: University Health Alliance Commercial	$69.73

STERNUM 2 VWS

Facility

$377.00

Service Code	HCPCS 71120
Hospital Charge Code	424711200
Hospital Revenue Code	320
Min. Negotiated Rate	$320.45
Max. Negotiated Rate	$365.69
Rate for Payer: Cash Price	$245.05
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: Kaiser Permanente Commercial	$339.30
Rate for Payer: MDX Hawaii PPO	$365.69

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC

Facility

$89,640.96

Service Code	MSDRG 327
Min. Negotiated Rate	$89,640.96
Max. Negotiated Rate	$89,640.96
Rate for Payer: Hawaii Medical Service Association Commercial	$89,640.96

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC

Facility

$126,639.79

Service Code	MSDRG 326
Min. Negotiated Rate	$126,639.79
Max. Negotiated Rate	$126,639.79
Rate for Payer: Hawaii Medical Service Association Commercial	$126,639.79

STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC

Facility

$38,373.54

Service Code	MSDRG 328
Min. Negotiated Rate	$38,373.54
Max. Negotiated Rate	$38,373.54
Rate for Payer: Hawaii Medical Service Association Commercial	$38,373.54

STOMACH TUBE (LEVIN TYPE) 12FR

Facility

$6.00

Hospital Charge Code	8294
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

STOMACH TUBE (LEVIN TYPE) 12FR

Facility

$6.00

Hospital Charge Code	8294
Hospital Revenue Code	272
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

Know your out-of-pocket cost for care.

All Charges