Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

terbutaline 1 mg/mL Sol [KMC]

Facility

$86.35

Service Code	HCPCS J3105
Hospital Revenue Code	636
Min. Negotiated Rate	$73.40
Max. Negotiated Rate	$83.76
Rate for Payer: Cash Price	$56.13
Rate for Payer: Health Management Network Commercial	$73.40
Rate for Payer: Kaiser Permanente Commercial	$77.72
Rate for Payer: MDX Hawaii PPO	$83.76

TESTES PROCEDURES WITH CC/MCC

Facility

$51,883.68

Service Code	MSDRG 711
Min. Negotiated Rate	$51,883.68
Max. Negotiated Rate	$51,883.68
Rate for Payer: Hawaii Medical Service Association Commercial	$51,883.68

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$36,714.40

Service Code	MSDRG 712
Min. Negotiated Rate	$36,714.40
Max. Negotiated Rate	$36,714.40
Rate for Payer: Hawaii Medical Service Association Commercial	$36,714.40

testosterone cypionate 200 mg / 1 mL vial [KMC]

Facility

$100.80

Service Code	HCPCS J1071
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$97.78
Rate for Payer: AlohaCare Medicaid	$50.40
Rate for Payer: AlohaCare Medicare	$42.34
Rate for Payer: Cash Price	$65.52
Rate for Payer: Cash Price	$65.52
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.74
Rate for Payer: Devoted Health Medicare	$42.34
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$42.34
Rate for Payer: Hawaii Western Management Group Commercial	$95.76
Rate for Payer: Health Management Network Commercial	$85.68
Rate for Payer: Humana Medicare	$42.34
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: Kaiser Permanente Medicaid	$51.41
Rate for Payer: Kaiser Permanente Medicare	$42.34
Rate for Payer: MDX Hawaii PPO	$97.78
Rate for Payer: Ohana Health Plan Medicaid	$42.34
Rate for Payer: Ohana Health Plan Medicare	$42.34
Rate for Payer: UnitedHealthcare Medicaid	$60.48
Rate for Payer: UnitedHealthcare Medicare	$42.34
Rate for Payer: University Health Alliance Commercial	$73.47

testosterone cypionate 200 mg / 1 mL vial [KMC]

Facility

$100.80

Service Code	HCPCS J1071
Hospital Revenue Code	636
Min. Negotiated Rate	$85.68
Max. Negotiated Rate	$97.78
Rate for Payer: Cash Price	$65.52
Rate for Payer: Health Management Network Commercial	$85.68
Rate for Payer: Kaiser Permanente Commercial	$90.72
Rate for Payer: MDX Hawaii PPO	$97.78

testosterone enanthate 200 mg/mL Inj[KMC]

Facility

$68.94

Service Code	HCPCS J3130
Hospital Revenue Code	636
Min. Negotiated Rate	$58.60
Max. Negotiated Rate	$66.87
Rate for Payer: Cash Price	$44.81
Rate for Payer: Health Management Network Commercial	$58.60
Rate for Payer: Kaiser Permanente Commercial	$62.05
Rate for Payer: MDX Hawaii PPO	$66.87

testosterone enanthate 200 mg/mL Inj[KMC]

Facility

$68.94

Service Code	HCPCS J3130
Hospital Revenue Code	636
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$66.87
Rate for Payer: AlohaCare Medicaid	$34.47
Rate for Payer: AlohaCare Medicare	$28.95
Rate for Payer: Cash Price	$44.81
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.42
Rate for Payer: Devoted Health Medicare	$28.95
Rate for Payer: Hawaii Medical Service Association Medicare	$28.95
Rate for Payer: Hawaii Western Management Group Commercial	$65.49
Rate for Payer: Health Management Network Commercial	$58.60
Rate for Payer: Humana Medicare	$28.95
Rate for Payer: Kaiser Permanente Commercial	$62.05
Rate for Payer: Kaiser Permanente Medicaid	$35.16
Rate for Payer: Kaiser Permanente Medicare	$28.95
Rate for Payer: MDX Hawaii PPO	$66.87
Rate for Payer: Ohana Health Plan Medicaid	$28.95
Rate for Payer: Ohana Health Plan Medicare	$28.95
Rate for Payer: UnitedHealthcare Medicaid	$41.36
Rate for Payer: UnitedHealthcare Medicare	$28.95
Rate for Payer: University Health Alliance Commercial	$50.25

Testosterone Free DLS

Facility

$54.00

Service Code	HCPCS 84402
Hospital Charge Code	422844025
Hospital Revenue Code	300
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

Testosterone Free DLS

Facility

$54.00

Service Code	HCPCS 84402
Hospital Charge Code	422844025
Hospital Revenue Code	300
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$65.80
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$22.68
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$49.68
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$35.19
Rate for Payer: Hawaii Medical Service Association Commercial	$31.84
Rate for Payer: Hawaii Medical Service Association Medicare	$22.68
Rate for Payer: Hawaii Western Management Group Commercial	$25.47
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$22.68
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$22.68
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$22.68
Rate for Payer: Ohana Health Plan Medicare	$22.68
Rate for Payer: UnitedHealthcare Medicaid	$35.19
Rate for Payer: UnitedHealthcare Medicare	$22.68
Rate for Payer: University Health Alliance Commercial	$65.80

Testosterone, Total and Free DLS

Facility

$392.00

Service Code	HCPCS 84402
Hospital Charge Code	422844025
Hospital Revenue Code	301
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

Testosterone, Total and Free DLS

Facility

$392.00

Service Code	HCPCS 84402
Hospital Charge Code	422844025
Hospital Revenue Code	301
Min. Negotiated Rate	$25.47
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$164.64
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$360.64
Rate for Payer: Devoted Health Medicare	$164.64
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$35.19
Rate for Payer: Hawaii Medical Service Association Commercial	$31.84
Rate for Payer: Hawaii Medical Service Association Medicare	$164.64
Rate for Payer: Hawaii Western Management Group Commercial	$25.47
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$164.64
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$164.64
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$164.64
Rate for Payer: Ohana Health Plan Medicare	$164.64
Rate for Payer: UnitedHealthcare Medicaid	$35.19
Rate for Payer: UnitedHealthcare Medicare	$164.64
Rate for Payer: University Health Alliance Commercial	$65.80

Testosterone, Total DLS

Facility

$198.00

Service Code	HCPCS 84403
Hospital Charge Code	422844035
Hospital Revenue Code	301
Min. Negotiated Rate	$168.30
Max. Negotiated Rate	$192.06
Rate for Payer: Cash Price	$128.70
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Kaiser Permanente Commercial	$178.20
Rate for Payer: MDX Hawaii PPO	$192.06

Testosterone, Total DLS

Facility

$198.00

Service Code	HCPCS 84403
Hospital Charge Code	422844035
Hospital Revenue Code	301
Min. Negotiated Rate	$25.81
Max. Negotiated Rate	$192.06
Rate for Payer: AlohaCare Medicaid	$99.00
Rate for Payer: AlohaCare Medicare	$83.16
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cash Price	$128.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$182.16
Rate for Payer: Devoted Health Medicare	$83.16
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$35.68
Rate for Payer: Hawaii Medical Service Association Commercial	$32.26
Rate for Payer: Hawaii Medical Service Association Medicare	$83.16
Rate for Payer: Hawaii Western Management Group Commercial	$25.81
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Humana Medicare	$83.16
Rate for Payer: Kaiser Permanente Commercial	$178.20
Rate for Payer: Kaiser Permanente Medicaid	$100.98
Rate for Payer: Kaiser Permanente Medicare	$83.16
Rate for Payer: MDX Hawaii PPO	$192.06
Rate for Payer: Ohana Health Plan Medicaid	$83.16
Rate for Payer: Ohana Health Plan Medicare	$83.16
Rate for Payer: UnitedHealthcare Medicaid	$35.68
Rate for Payer: UnitedHealthcare Medicare	$83.16
Rate for Payer: University Health Alliance Commercial	$66.75

tetanus-diphth toxoids (Td) 0.5 mL susp [KMC]

Facility

$322.38

Service Code	HCPCS 90714
Hospital Revenue Code	637
Min. Negotiated Rate	$274.02
Max. Negotiated Rate	$312.71
Rate for Payer: Cash Price	$209.55
Rate for Payer: Health Management Network Commercial	$274.02
Rate for Payer: Kaiser Permanente Commercial	$290.14
Rate for Payer: MDX Hawaii PPO	$312.71

tetanus-diphth toxoids (Td) 0.5 mL susp [KMC]

Facility

$322.38

Service Code	HCPCS 90714
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$312.71
Rate for Payer: AlohaCare Medicaid	$161.19
Rate for Payer: AlohaCare Medicare	$135.40
Rate for Payer: Cash Price	$209.55
Rate for Payer: Cash Price	$209.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$296.59
Rate for Payer: Devoted Health Medicare	$135.40
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$33.48
Rate for Payer: Hawaii Medical Service Association Medicare	$135.40
Rate for Payer: Hawaii Western Management Group Commercial	$306.26
Rate for Payer: Health Management Network Commercial	$274.02
Rate for Payer: Humana Medicare	$135.40
Rate for Payer: Kaiser Permanente Commercial	$290.14
Rate for Payer: Kaiser Permanente Medicaid	$164.41
Rate for Payer: Kaiser Permanente Medicare	$135.40
Rate for Payer: MDX Hawaii PPO	$312.71
Rate for Payer: Ohana Health Plan Medicaid	$135.40
Rate for Payer: Ohana Health Plan Medicare	$135.40
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$135.40
Rate for Payer: University Health Alliance Commercial	$234.98

theophylline 100 mg ER [KMC]

Facility

$3.00

Service Code	NDC 50111048301
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

theophylline 100 mg ER [KMC]

Facility

$3.00

Service Code	NDC 50111048301
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

theophylline 300 mg ER Tab [KMC]

Facility

$17.18

Service Code	NDC 62332002531
Hospital Revenue Code	250
Min. Negotiated Rate	$14.60
Max. Negotiated Rate	$16.66
Rate for Payer: Cash Price	$11.17
Rate for Payer: Health Management Network Commercial	$14.60
Rate for Payer: Kaiser Permanente Commercial	$15.46
Rate for Payer: MDX Hawaii PPO	$16.66

theophylline 300 mg ER Tab [KMC]

Facility

$17.18

Service Code	NDC 62332002531
Hospital Revenue Code	250
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$16.66
Rate for Payer: AlohaCare Medicaid	$8.59
Rate for Payer: AlohaCare Medicare	$7.22
Rate for Payer: Cash Price	$11.17
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.81
Rate for Payer: Devoted Health Medicare	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$7.22
Rate for Payer: Hawaii Western Management Group Commercial	$16.32
Rate for Payer: Health Management Network Commercial	$14.60
Rate for Payer: Humana Medicare	$7.22
Rate for Payer: Kaiser Permanente Commercial	$15.46
Rate for Payer: Kaiser Permanente Medicaid	$8.76
Rate for Payer: Kaiser Permanente Medicare	$7.22
Rate for Payer: MDX Hawaii PPO	$16.66
Rate for Payer: Ohana Health Plan Medicaid	$7.22
Rate for Payer: Ohana Health Plan Medicare	$7.22
Rate for Payer: UnitedHealthcare Medicaid	$10.31
Rate for Payer: UnitedHealthcare Medicare	$7.22
Rate for Payer: University Health Alliance Commercial	$12.52

theophylline 400 mg/24 hours ER tab [KMC]

Facility

$4.97

Service Code	NDC 42858070101
Hospital Revenue Code	250
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$4.82
Rate for Payer: AlohaCare Medicaid	$2.48
Rate for Payer: AlohaCare Medicare	$2.09
Rate for Payer: Cash Price	$3.23
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.57
Rate for Payer: Devoted Health Medicare	$2.09
Rate for Payer: Hawaii Medical Service Association Medicare	$2.09
Rate for Payer: Hawaii Western Management Group Commercial	$4.72
Rate for Payer: Health Management Network Commercial	$4.22
Rate for Payer: Humana Medicare	$2.09
Rate for Payer: Kaiser Permanente Commercial	$4.47
Rate for Payer: Kaiser Permanente Medicaid	$2.53
Rate for Payer: Kaiser Permanente Medicare	$2.09
Rate for Payer: MDX Hawaii PPO	$4.82
Rate for Payer: Ohana Health Plan Medicaid	$2.09
Rate for Payer: Ohana Health Plan Medicare	$2.09
Rate for Payer: UnitedHealthcare Medicaid	$2.98
Rate for Payer: UnitedHealthcare Medicare	$2.09
Rate for Payer: University Health Alliance Commercial	$3.62

theophylline 400 mg/24 hours ER tab [KMC]

Facility

$4.97

Service Code	NDC 42858070101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$4.82
Rate for Payer: Cash Price	$3.23
Rate for Payer: Health Management Network Commercial	$4.22
Rate for Payer: Kaiser Permanente Commercial	$4.47
Rate for Payer: MDX Hawaii PPO	$4.82

Theophylline DLS

Facility

$336.00

Service Code	HCPCS 80198
Hospital Charge Code	422801985
Hospital Revenue Code	301
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$325.92
Rate for Payer: Cash Price	$218.40
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: MDX Hawaii PPO	$325.92

Theophylline DLS

Facility

$336.00

Service Code	HCPCS 80198
Hospital Charge Code	422801985
Hospital Revenue Code	301
Min. Negotiated Rate	$14.14
Max. Negotiated Rate	$325.92
Rate for Payer: AlohaCare Medicaid	$168.00
Rate for Payer: AlohaCare Medicare	$141.12
Rate for Payer: Cash Price	$218.40
Rate for Payer: Cash Price	$218.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$309.12
Rate for Payer: Devoted Health Medicare	$141.12
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.56
Rate for Payer: Hawaii Medical Service Association Commercial	$17.68
Rate for Payer: Hawaii Medical Service Association Medicare	$141.12
Rate for Payer: Hawaii Western Management Group Commercial	$14.14
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Humana Medicare	$141.12
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: Kaiser Permanente Medicaid	$171.36
Rate for Payer: Kaiser Permanente Medicare	$141.12
Rate for Payer: MDX Hawaii PPO	$325.92
Rate for Payer: Ohana Health Plan Medicaid	$141.12
Rate for Payer: Ohana Health Plan Medicare	$141.12
Rate for Payer: UnitedHealthcare Medicaid	$19.56
Rate for Payer: UnitedHealthcare Medicare	$141.12
Rate for Payer: University Health Alliance Commercial	$36.57

THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN

Professional

Both

$162.00

Service Code	HCPCS 97530
Hospital Revenue Code	420
Min. Negotiated Rate	$20.94
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$39.69
Rate for Payer: AlohaCare Medicare	$37.68
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$37.68
Rate for Payer: Hawaii Medical Service Association Medicare	$37.68
Rate for Payer: Hawaii Western Management Group Commercial	$20.94
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$45.22
Rate for Payer: Kaiser Permanente Medicaid	$45.22
Rate for Payer: Kaiser Permanente Medicare	$45.22
Rate for Payer: Ohana Health Plan Medicaid	$39.69
Rate for Payer: Ohana Health Plan Medicare	$37.68
Rate for Payer: UnitedHealthcare Medicaid	$39.69
Rate for Payer: UnitedHealthcare Medicare	$37.68

THERAPEUTIC ACT EA 15 MIN Occupational

Facility

$179.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	426975300
Hospital Revenue Code	430
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

Know your out-of-pocket cost for care.

All Charges