Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Streptozyme DLS

Facility

$124.00

Service Code	HCPCS 86403
Hospital Charge Code	422864035
Hospital Revenue Code	306
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$80.60
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

SUB PT/OT CURRENT STATUS

Professional

Both

$0.01

Service Code	HCPCS G8993
Hospital Revenue Code	420
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

SUB PT/OT CURRENT STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8993 GO
Hospital Charge Code	426G89930
Hospital Revenue Code	430
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

SUB PT/OT CURRENT STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8993 GO
Hospital Charge Code	426G89930
Hospital Revenue Code	430
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

SUB PT/OT CURRENT STATUS Physical

Facility

$1.00

Service Code	HCPCS G8993 GP
Hospital Charge Code	432G89930
Hospital Revenue Code	420
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

SUB PT/OT CURRENT STATUS Physical

Facility

$1.00

Service Code	HCPCS G8993 GP
Hospital Charge Code	432G89930
Hospital Revenue Code	420
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

SUB PT/OT D/C STATUS

Professional

Both

$0.01

Service Code	HCPCS G8995
Hospital Revenue Code	420
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

SUB PT/OT D/C STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8995 GO
Hospital Charge Code	426G89950
Hospital Revenue Code	430
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

SUB PT/OT D/C STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8995 GO
Hospital Charge Code	426G89950
Hospital Revenue Code	430
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

SUB PT/OT D/C STATUS Physical

Facility

$1.00

Service Code	HCPCS G8995 GP
Hospital Charge Code	432G89950
Hospital Revenue Code	420
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

SUB PT/OT D/C STATUS Physical

Facility

$1.00

Service Code	HCPCS G8995 GP
Hospital Charge Code	432G89950
Hospital Revenue Code	420
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

SUB PT/OT GOAL STATUS

Professional

Both

$0.01

Service Code	HCPCS G8994
Hospital Revenue Code	420
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

SUB PT/OT GOAL STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8994 GO
Hospital Charge Code	426G89940
Hospital Revenue Code	430
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

SUB PT/OT GOAL STATUS Occupational

Facility

$2.00

Service Code	HCPCS G8994 GO
Hospital Charge Code	426G89940
Hospital Revenue Code	430
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

SUB PT/OT GOAL STATUS Physical

Facility

$1.00

Service Code	HCPCS G8994 GP
Hospital Charge Code	432G89940
Hospital Revenue Code	420
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

SUB PT/OT GOAL STATUS Physical

Facility

$1.00

Service Code	HCPCS G8994 GP
Hospital Charge Code	432G89940
Hospital Revenue Code	420
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

Subseq Hospital Care Level 1 - 99231

Professional

Both

$118.00

Service Code	HCPCS 99231
Hospital Charge Code	435992310
Hospital Revenue Code	987
Min. Negotiated Rate	$36.28
Max. Negotiated Rate	$100.30
Rate for Payer: AlohaCare Medicaid	$49.50
Rate for Payer: AlohaCare Medicare	$44.06
Rate for Payer: Cash Price	$76.70
Rate for Payer: Cash Price	$76.70
Rate for Payer: Devoted Health Medicare	$44.06
Rate for Payer: Hawaii Medical Service Association Medicare	$44.06
Rate for Payer: Hawaii Western Management Group Commercial	$36.28
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$52.87
Rate for Payer: Kaiser Permanente Medicaid	$52.87
Rate for Payer: Kaiser Permanente Medicare	$52.87
Rate for Payer: Ohana Health Plan Medicaid	$49.50
Rate for Payer: Ohana Health Plan Medicare	$44.06
Rate for Payer: UnitedHealthcare Medicaid	$49.50
Rate for Payer: UnitedHealthcare Medicare	$44.06

Subseq Hospital Care Level 2 - 99232

Professional

Both

$218.00

Service Code	HCPCS 99232
Hospital Charge Code	435992320
Hospital Revenue Code	987
Min. Negotiated Rate	$54.57
Max. Negotiated Rate	$185.30
Rate for Payer: AlohaCare Medicaid	$79.26
Rate for Payer: AlohaCare Medicare	$70.62
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$70.62
Rate for Payer: Hawaii Medical Service Association Medicare	$70.62
Rate for Payer: Hawaii Western Management Group Commercial	$54.57
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$84.74
Rate for Payer: Kaiser Permanente Medicaid	$84.74
Rate for Payer: Kaiser Permanente Medicare	$84.74
Rate for Payer: Ohana Health Plan Medicaid	$79.26
Rate for Payer: Ohana Health Plan Medicare	$70.62
Rate for Payer: UnitedHealthcare Medicaid	$79.26
Rate for Payer: UnitedHealthcare Medicare	$70.62

Subseq Hospital Care Level 3 - 99233

Professional

Both

$314.00

Service Code	HCPCS 99233
Hospital Charge Code	435992330
Hospital Revenue Code	987
Min. Negotiated Rate	$76.28
Max. Negotiated Rate	$266.90
Rate for Payer: AlohaCare Medicaid	$119.20
Rate for Payer: AlohaCare Medicare	$107.19
Rate for Payer: Cash Price	$204.10
Rate for Payer: Cash Price	$204.10
Rate for Payer: Devoted Health Medicare	$107.19
Rate for Payer: Hawaii Medical Service Association Medicare	$107.19
Rate for Payer: Hawaii Western Management Group Commercial	$76.28
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Kaiser Permanente Commercial	$128.63
Rate for Payer: Kaiser Permanente Medicaid	$128.63
Rate for Payer: Kaiser Permanente Medicare	$128.63
Rate for Payer: Ohana Health Plan Medicaid	$119.20
Rate for Payer: Ohana Health Plan Medicare	$107.19
Rate for Payer: UnitedHealthcare Medicaid	$119.20
Rate for Payer: UnitedHealthcare Medicare	$107.19

Subsequent eval mgmnt of pt an annual nsg facility

Professional

Both

$279.00

Service Code	HCPCS 99309
Hospital Charge Code	435993090
Hospital Revenue Code	987
Min. Negotiated Rate	$69.47
Max. Negotiated Rate	$237.15
Rate for Payer: AlohaCare Medicaid	$110.71
Rate for Payer: AlohaCare Medicare	$100.64
Rate for Payer: Cash Price	$181.35
Rate for Payer: Cash Price	$181.35
Rate for Payer: Devoted Health Medicare	$100.64
Rate for Payer: Hawaii Medical Service Association Medicare	$100.64
Rate for Payer: Hawaii Western Management Group Commercial	$69.47
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: Kaiser Permanente Commercial	$120.77
Rate for Payer: Kaiser Permanente Medicaid	$120.77
Rate for Payer: Kaiser Permanente Medicare	$120.77
Rate for Payer: Ohana Health Plan Medicaid	$110.71
Rate for Payer: Ohana Health Plan Medicare	$100.64
Rate for Payer: UnitedHealthcare Medicaid	$110.71
Rate for Payer: UnitedHealthcare Medicare	$100.64

Subsequent nursing facility care (History, Examina

Professional

Both

$213.00

Service Code	HCPCS 99308
Hospital Charge Code	435993080
Hospital Revenue Code	987
Min. Negotiated Rate	$50.97
Max. Negotiated Rate	$181.05
Rate for Payer: AlohaCare Medicaid	$76.70
Rate for Payer: AlohaCare Medicare	$69.65
Rate for Payer: Cash Price	$138.45
Rate for Payer: Cash Price	$138.45
Rate for Payer: Devoted Health Medicare	$69.65
Rate for Payer: Hawaii Medical Service Association Medicare	$69.65
Rate for Payer: Hawaii Western Management Group Commercial	$50.97
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$83.58
Rate for Payer: Kaiser Permanente Medicaid	$83.58
Rate for Payer: Kaiser Permanente Medicare	$83.58
Rate for Payer: Ohana Health Plan Medicaid	$76.70
Rate for Payer: Ohana Health Plan Medicare	$69.65
Rate for Payer: UnitedHealthcare Medicaid	$76.70
Rate for Payer: UnitedHealthcare Medicare	$69.65

SUBSEQUENT OBSERVATION CARE STABLE

Professional

Both

$120.00

Service Code	HCPCS 99224
Hospital Charge Code	400992240
Hospital Revenue Code	987
Min. Negotiated Rate	$39.86
Max. Negotiated Rate	$102.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Hawaii Western Management Group Commercial	$39.86
Rate for Payer: Health Management Network Commercial	$102.00

SUBS NF CARE HIGH 35 MIN

Professional

Both

$413.00

Service Code	HCPCS 99310
Hospital Charge Code	400993100
Hospital Revenue Code	987
Min. Negotiated Rate	$111.74
Max. Negotiated Rate	$351.05
Rate for Payer: AlohaCare Medicaid	$157.37
Rate for Payer: AlohaCare Medicare	$142.78
Rate for Payer: Cash Price	$268.45
Rate for Payer: Cash Price	$268.45
Rate for Payer: Devoted Health Medicare	$142.78
Rate for Payer: Hawaii Medical Service Association Medicare	$142.78
Rate for Payer: Hawaii Western Management Group Commercial	$111.74
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$171.34
Rate for Payer: Kaiser Permanente Medicaid	$171.34
Rate for Payer: Kaiser Permanente Medicare	$171.34
Rate for Payer: Ohana Health Plan Medicaid	$157.37
Rate for Payer: Ohana Health Plan Medicare	$142.78
Rate for Payer: UnitedHealthcare Medicaid	$157.37
Rate for Payer: UnitedHealthcare Medicare	$142.78

SUBSQNT OBSERVATN CARE MINOR COMPLIC

Professional

Both

$219.00

Service Code	HCPCS 99225
Hospital Charge Code	400992250
Hospital Revenue Code	987
Min. Negotiated Rate	$72.52
Max. Negotiated Rate	$186.15
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Hawaii Western Management Group Commercial	$72.52
Rate for Payer: Health Management Network Commercial	$186.15

SUBSQNT OBSERVATN CARE SEVER COMPLIC

Professional

Both

$317.00

Service Code	HCPCS 99226
Hospital Charge Code	400992260
Hospital Revenue Code	987
Min. Negotiated Rate	$104.81
Max. Negotiated Rate	$269.45
Rate for Payer: Cash Price	$206.05
Rate for Payer: Cash Price	$206.05
Rate for Payer: Hawaii Western Management Group Commercial	$104.81
Rate for Payer: Health Management Network Commercial	$269.45

Know your out-of-pocket cost for care.

All Charges