Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

SUPER SPONGE

Facility

$3.00

Hospital Charge Code	8303
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

SUPER SPONGE

Facility

$3.00

Hospital Charge Code	8303
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

SURE VENTLINE NEO-ADULT

Facility

$34.00

Hospital Charge Code	8427
Hospital Revenue Code	270
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

SURE VENTLINE NEO-ADULT

Facility

$34.00

Hospital Charge Code	8427
Hospital Revenue Code	270
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$14.28
Rate for Payer: Cash Price	$22.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.28
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association Medicare	$14.28
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$14.28
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$14.28
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$14.28
Rate for Payer: Ohana Health Plan Medicare	$14.28
Rate for Payer: UnitedHealthcare Medicare	$14.28
Rate for Payer: University Health Alliance Commercial	$24.78

SURGICAL CAP

Facility

$34.00

Hospital Charge Code	8304
Hospital Revenue Code	270
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$22.10
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

SURGICAL CAP

Facility

$34.00

Hospital Charge Code	8304
Hospital Revenue Code	270
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$32.98
Rate for Payer: AlohaCare Medicaid	$17.00
Rate for Payer: AlohaCare Medicare	$14.28
Rate for Payer: Cash Price	$22.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$31.28
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Hawaii Medical Service Association Medicare	$14.28
Rate for Payer: Hawaii Western Management Group Commercial	$32.30
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Humana Medicare	$14.28
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: Kaiser Permanente Medicaid	$17.34
Rate for Payer: Kaiser Permanente Medicare	$14.28
Rate for Payer: MDX Hawaii PPO	$32.98
Rate for Payer: Ohana Health Plan Medicaid	$14.28
Rate for Payer: Ohana Health Plan Medicare	$14.28
Rate for Payer: UnitedHealthcare Medicare	$14.28
Rate for Payer: University Health Alliance Commercial	$24.78

SURROUND ANKLE GEL 10"

Facility

$39.00

Hospital Charge Code	8305
Hospital Revenue Code	274
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$25.35
Rate for Payer: Hawaii Western Management Group Commercial	$27.30
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: University Health Alliance Commercial	$21.84

SURROUND ANKLE GEL 10"

Facility

$39.00

Hospital Charge Code	8305
Hospital Revenue Code	274
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$37.83
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$16.38
Rate for Payer: Cash Price	$25.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$35.88
Rate for Payer: Devoted Health Medicare	$16.38
Rate for Payer: Hawaii Medical Service Association Medicare	$16.38
Rate for Payer: Hawaii Western Management Group Commercial	$27.30
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Humana Medicare	$16.38
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicare	$16.38
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$16.38
Rate for Payer: UnitedHealthcare Medicare	$16.38
Rate for Payer: University Health Alliance Commercial	$21.84

SURROUND ANKLE GEL 8.5"

Facility

$47.00

Hospital Charge Code	8306
Hospital Revenue Code	274
Min. Negotiated Rate	$19.74
Max. Negotiated Rate	$45.59
Rate for Payer: AlohaCare Medicaid	$23.50
Rate for Payer: AlohaCare Medicare	$19.74
Rate for Payer: Cash Price	$30.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$43.24
Rate for Payer: Devoted Health Medicare	$19.74
Rate for Payer: Hawaii Medical Service Association Medicare	$19.74
Rate for Payer: Hawaii Western Management Group Commercial	$32.90
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Humana Medicare	$19.74
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: Kaiser Permanente Medicare	$19.74
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: Ohana Health Plan Medicaid	$19.74
Rate for Payer: Ohana Health Plan Medicare	$19.74
Rate for Payer: UnitedHealthcare Medicare	$19.74
Rate for Payer: University Health Alliance Commercial	$26.32

SURROUND ANKLE GEL 8.5"

Facility

$47.00

Hospital Charge Code	8306
Hospital Revenue Code	274
Min. Negotiated Rate	$26.32
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$30.55
Rate for Payer: Hawaii Western Management Group Commercial	$32.90
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: University Health Alliance Commercial	$26.32

SURROUND ANKLE GEL 9"

Facility

$48.00

Hospital Charge Code	8307
Hospital Revenue Code	274
Min. Negotiated Rate	$26.88
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$31.20
Rate for Payer: Hawaii Western Management Group Commercial	$33.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: University Health Alliance Commercial	$26.88

SURROUND ANKLE GEL 9"

Facility

$48.00

Hospital Charge Code	8307
Hospital Revenue Code	274
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$20.16
Rate for Payer: Cash Price	$31.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$44.16
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$20.16
Rate for Payer: Hawaii Western Management Group Commercial	$33.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$20.16
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$20.16
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$20.16
Rate for Payer: Ohana Health Plan Medicare	$20.16
Rate for Payer: UnitedHealthcare Medicare	$20.16
Rate for Payer: University Health Alliance Commercial	$26.88

SUTURE CHROMIC GUT 3-0

Facility

$73.00

Hospital Charge Code	8807
Hospital Revenue Code	270
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$47.45
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

SUTURE CHROMIC GUT 3-0

Facility

$73.00

Hospital Charge Code	8807
Hospital Revenue Code	270
Min. Negotiated Rate	$30.66
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$30.66
Rate for Payer: Cash Price	$47.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$67.16
Rate for Payer: Devoted Health Medicare	$30.66
Rate for Payer: Hawaii Medical Service Association Medicare	$30.66
Rate for Payer: Hawaii Western Management Group Commercial	$69.35
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$30.66
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$30.66
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$30.66
Rate for Payer: Ohana Health Plan Medicare	$30.66
Rate for Payer: UnitedHealthcare Medicare	$30.66
Rate for Payer: University Health Alliance Commercial	$53.21

SUTURE CHROMIC GUT 3-0 FS-2

Facility

$5.00

Hospital Charge Code	8308
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

SUTURE CHROMIC GUT 3-0 FS-2

Facility

$5.00

Hospital Charge Code	8308
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

SUTURE CHROMIC GUT 4-0 PS-2

Facility

$5.00

Hospital Charge Code	8309
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

SUTURE CHROMIC GUT 4-0 PS-2

Facility

$5.00

Hospital Charge Code	8309
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

SUTURE CHROMIC GUT 5-0 FS-2 BOX 12

Facility

$125.00

Hospital Charge Code	8805
Hospital Revenue Code	270
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$62.50
Rate for Payer: AlohaCare Medicare	$52.50
Rate for Payer: Cash Price	$81.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$115.00
Rate for Payer: Devoted Health Medicare	$52.50
Rate for Payer: Hawaii Medical Service Association Medicare	$52.50
Rate for Payer: Hawaii Western Management Group Commercial	$118.75
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Humana Medicare	$52.50
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$52.50
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: Ohana Health Plan Medicaid	$52.50
Rate for Payer: Ohana Health Plan Medicare	$52.50
Rate for Payer: UnitedHealthcare Medicare	$52.50
Rate for Payer: University Health Alliance Commercial	$91.11

SUTURE CHROMIC GUT 5-0 FS-2 BOX 12

Facility

$125.00

Hospital Charge Code	8805
Hospital Revenue Code	270
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Kaiser Permanente Commercial	$112.50
Rate for Payer: MDX Hawaii PPO	$121.25

SUTURE CHROMIC GUT 5-0 P-3

Facility

$24.00

Hospital Charge Code	8806
Hospital Revenue Code	270
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$10.08
Rate for Payer: Cash Price	$15.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.08
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Hawaii Medical Service Association Medicare	$10.08
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$10.08
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$10.08
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$10.08
Rate for Payer: Ohana Health Plan Medicare	$10.08
Rate for Payer: UnitedHealthcare Medicare	$10.08
Rate for Payer: University Health Alliance Commercial	$17.49

SUTURE CHROMIC GUT 5-0 P-3

Facility

$24.00

Hospital Charge Code	8806
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

SUTURE ETHILON 3-0 FS-1 BX/24

Facility

$5.00

Hospital Charge Code	8310
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

SUTURE ETHILON 3-0 FS-1 BX/24

Facility

$5.00

Hospital Charge Code	8310
Hospital Revenue Code	270
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

SUTURE ETHILON 3-0 FS-1 BX/36

Facility

$4.00

Hospital Charge Code	8311
Hospital Revenue Code	270
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

Know your out-of-pocket cost for care.

All Charges