Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM

Professional

Both

$81.00

Service Code	HCPCS 96372
Hospital Revenue Code	636
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$68.85
Rate for Payer: AlohaCare Medicaid	$9.24
Rate for Payer: AlohaCare Medicare	$16.51
Rate for Payer: Cash Price	$52.65
Rate for Payer: Cash Price	$52.65
Rate for Payer: Devoted Health Medicare	$16.51
Rate for Payer: Hawaii Medical Service Association Medicare	$16.51
Rate for Payer: Hawaii Western Management Group Commercial	$17.25
Rate for Payer: Health Management Network Commercial	$68.85
Rate for Payer: Kaiser Permanente Commercial	$19.81
Rate for Payer: Kaiser Permanente Medicaid	$19.81
Rate for Payer: Kaiser Permanente Medicare	$19.81
Rate for Payer: Ohana Health Plan Medicaid	$9.24
Rate for Payer: Ohana Health Plan Medicare	$16.51
Rate for Payer: UnitedHealthcare Medicaid	$9.24
Rate for Payer: UnitedHealthcare Medicare	$16.51

THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES

Professional

Both

$162.00

Service Code	HCPCS 97110
Hospital Revenue Code	420
Min. Negotiated Rate	$20.52
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$31.23
Rate for Payer: AlohaCare Medicare	$30.79
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$30.79
Rate for Payer: Hawaii Medical Service Association Medicare	$30.79
Rate for Payer: Hawaii Western Management Group Commercial	$20.52
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$36.95
Rate for Payer: Kaiser Permanente Medicaid	$36.95
Rate for Payer: Kaiser Permanente Medicare	$36.95
Rate for Payer: Ohana Health Plan Medicaid	$31.23
Rate for Payer: Ohana Health Plan Medicare	$30.79
Rate for Payer: UnitedHealthcare Medicaid	$31.23
Rate for Payer: UnitedHealthcare Medicare	$30.79

THERAP PROC EA 15 MIN Occupational

Facility

$179.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	426971100
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

THERAP PROC EA 15 MIN Occupational

Facility

$179.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	426971100
Hospital Revenue Code	430
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$17.65
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

THER PX 1/> AREAS EA 15 MIN GAIT TRAING W/STAIR

Professional

Both

$162.00

Service Code	HCPCS 97116
Hospital Revenue Code	420
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$31.23
Rate for Payer: AlohaCare Medicare	$30.79
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$30.79
Rate for Payer: Hawaii Medical Service Association Medicare	$30.79
Rate for Payer: Hawaii Western Management Group Commercial	$17.70
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$36.95
Rate for Payer: Kaiser Permanente Medicaid	$36.95
Rate for Payer: Kaiser Permanente Medicare	$36.95
Rate for Payer: Ohana Health Plan Medicaid	$31.23
Rate for Payer: Ohana Health Plan Medicare	$30.79
Rate for Payer: UnitedHealthcare Medicaid	$31.23
Rate for Payer: UnitedHealthcare Medicare	$30.79

THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA

Professional

Both

$162.00

Service Code	HCPCS 97112
Hospital Revenue Code	420
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$35.95
Rate for Payer: AlohaCare Medicare	$34.74
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$34.74
Rate for Payer: Hawaii Medical Service Association Medicare	$34.74
Rate for Payer: Hawaii Western Management Group Commercial	$19.83
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$41.69
Rate for Payer: Kaiser Permanente Medicaid	$41.69
Rate for Payer: Kaiser Permanente Medicare	$41.69
Rate for Payer: Ohana Health Plan Medicaid	$35.95
Rate for Payer: Ohana Health Plan Medicare	$34.74
Rate for Payer: UnitedHealthcare Medicaid	$35.95
Rate for Payer: UnitedHealthcare Medicare	$34.74

THER PX 1/> AREAS EACH 15 MINUTES MASSAGE

Professional

Both

$162.00

Service Code	HCPCS 97124
Hospital Revenue Code	420
Min. Negotiated Rate	$16.03
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$32.87
Rate for Payer: AlohaCare Medicare	$32.01
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$32.01
Rate for Payer: Hawaii Medical Service Association Medicare	$32.01
Rate for Payer: Hawaii Western Management Group Commercial	$16.03
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$38.41
Rate for Payer: Kaiser Permanente Medicaid	$38.41
Rate for Payer: Kaiser Permanente Medicare	$38.41
Rate for Payer: Ohana Health Plan Medicaid	$32.87
Rate for Payer: Ohana Health Plan Medicare	$32.01
Rate for Payer: UnitedHealthcare Medicaid	$32.87
Rate for Payer: UnitedHealthcare Medicare	$32.01

thiamine 100 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 31604001281
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

thiamine 100 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 31604001281
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

thiamine 200 mg / 2 mL Inj Sol [KMC]

Facility

$22.59

Service Code	HCPCS J3411
Hospital Revenue Code	636
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$21.91
Rate for Payer: AlohaCare Medicaid	$11.29
Rate for Payer: AlohaCare Medicare	$9.49
Rate for Payer: Cash Price	$14.68
Rate for Payer: Cash Price	$14.68
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$20.78
Rate for Payer: Devoted Health Medicare	$9.49
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$1.79
Rate for Payer: Hawaii Medical Service Association Medicare	$9.49
Rate for Payer: Hawaii Western Management Group Commercial	$21.46
Rate for Payer: Health Management Network Commercial	$19.20
Rate for Payer: Humana Medicare	$9.49
Rate for Payer: Kaiser Permanente Commercial	$20.33
Rate for Payer: Kaiser Permanente Medicaid	$11.52
Rate for Payer: Kaiser Permanente Medicare	$9.49
Rate for Payer: MDX Hawaii PPO	$21.91
Rate for Payer: Ohana Health Plan Medicaid	$9.49
Rate for Payer: Ohana Health Plan Medicare	$9.49
Rate for Payer: UnitedHealthcare Medicaid	$13.55
Rate for Payer: UnitedHealthcare Medicare	$9.49
Rate for Payer: University Health Alliance Commercial	$16.47

thiamine 200 mg / 2 mL Inj Sol [KMC]

Facility

$22.59

Service Code	HCPCS J3411
Hospital Revenue Code	636
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$21.91
Rate for Payer: Cash Price	$14.68
Rate for Payer: Health Management Network Commercial	$19.20
Rate for Payer: Kaiser Permanente Commercial	$20.33
Rate for Payer: MDX Hawaii PPO	$21.91

Throat Culture DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$54.18
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.68
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$54.18
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$54.18
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$54.18
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$54.18
Rate for Payer: Ohana Health Plan Medicare	$54.18
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$54.18
Rate for Payer: University Health Alliance Commercial	$22.26

Throat Culture DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

THUMB SPICA RT L/XL

Facility

$643.00

Hospital Charge Code	8503
Hospital Revenue Code	272
Min. Negotiated Rate	$270.06
Max. Negotiated Rate	$623.71
Rate for Payer: AlohaCare Medicaid	$321.50
Rate for Payer: AlohaCare Medicare	$270.06
Rate for Payer: Cash Price	$417.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$591.56
Rate for Payer: Devoted Health Medicare	$270.06
Rate for Payer: Hawaii Medical Service Association Medicare	$270.06
Rate for Payer: Hawaii Western Management Group Commercial	$610.85
Rate for Payer: Health Management Network Commercial	$546.55
Rate for Payer: Humana Medicare	$270.06
Rate for Payer: Kaiser Permanente Commercial	$578.70
Rate for Payer: Kaiser Permanente Medicaid	$327.93
Rate for Payer: Kaiser Permanente Medicare	$270.06
Rate for Payer: MDX Hawaii PPO	$623.71
Rate for Payer: Ohana Health Plan Medicaid	$270.06
Rate for Payer: Ohana Health Plan Medicare	$270.06
Rate for Payer: UnitedHealthcare Medicare	$270.06
Rate for Payer: University Health Alliance Commercial	$468.68

THUMB SPICA RT L/XL

Facility

$643.00

Hospital Charge Code	8503
Hospital Revenue Code	272
Min. Negotiated Rate	$546.55
Max. Negotiated Rate	$623.71
Rate for Payer: Cash Price	$417.95
Rate for Payer: Health Management Network Commercial	$546.55
Rate for Payer: Kaiser Permanente Commercial	$578.70
Rate for Payer: MDX Hawaii PPO	$623.71

thyroid desiccated 120 mg Tab [KMC]

Facility

$6.97

Service Code	NDC 42192032801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$6.76
Rate for Payer: AlohaCare Medicaid	$3.48
Rate for Payer: AlohaCare Medicare	$2.93
Rate for Payer: Cash Price	$4.53
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.41
Rate for Payer: Devoted Health Medicare	$2.93
Rate for Payer: Hawaii Medical Service Association Medicare	$2.93
Rate for Payer: Hawaii Western Management Group Commercial	$6.62
Rate for Payer: Health Management Network Commercial	$5.92
Rate for Payer: Humana Medicare	$2.93
Rate for Payer: Kaiser Permanente Commercial	$6.27
Rate for Payer: Kaiser Permanente Medicaid	$3.55
Rate for Payer: Kaiser Permanente Medicare	$2.93
Rate for Payer: MDX Hawaii PPO	$6.76
Rate for Payer: Ohana Health Plan Medicaid	$2.93
Rate for Payer: Ohana Health Plan Medicare	$2.93
Rate for Payer: UnitedHealthcare Medicaid	$4.18
Rate for Payer: UnitedHealthcare Medicare	$2.93
Rate for Payer: University Health Alliance Commercial	$5.08

thyroid desiccated 120 mg Tab [KMC]

Facility

$6.97

Service Code	NDC 42192032801
Hospital Revenue Code	250
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$6.76
Rate for Payer: Cash Price	$4.53
Rate for Payer: Health Management Network Commercial	$5.92
Rate for Payer: Kaiser Permanente Commercial	$6.27
Rate for Payer: MDX Hawaii PPO	$6.76

thyroid desiccated 15 mg Tab [KMC]

Facility

$3.39

Service Code	NDC 42192032701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$3.29
Rate for Payer: AlohaCare Medicaid	$1.70
Rate for Payer: AlohaCare Medicare	$1.42
Rate for Payer: Cash Price	$2.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.12
Rate for Payer: Devoted Health Medicare	$1.42
Rate for Payer: Hawaii Medical Service Association Medicare	$1.42
Rate for Payer: Hawaii Western Management Group Commercial	$3.22
Rate for Payer: Health Management Network Commercial	$2.88
Rate for Payer: Humana Medicare	$1.42
Rate for Payer: Kaiser Permanente Commercial	$3.05
Rate for Payer: Kaiser Permanente Medicaid	$1.73
Rate for Payer: Kaiser Permanente Medicare	$1.42
Rate for Payer: MDX Hawaii PPO	$3.29
Rate for Payer: Ohana Health Plan Medicaid	$1.42
Rate for Payer: Ohana Health Plan Medicare	$1.42
Rate for Payer: UnitedHealthcare Medicaid	$2.03
Rate for Payer: UnitedHealthcare Medicare	$1.42
Rate for Payer: University Health Alliance Commercial	$2.47

thyroid desiccated 15 mg Tab [KMC]

Facility

$3.39

Service Code	NDC 42192032701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$3.29
Rate for Payer: Cash Price	$2.20
Rate for Payer: Health Management Network Commercial	$2.88
Rate for Payer: Kaiser Permanente Commercial	$3.05
Rate for Payer: MDX Hawaii PPO	$3.29

thyroid desiccated 30 mg Tab [KMC]

Facility

$4.18

Service Code	NDC 75834031101
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.05
Rate for Payer: AlohaCare Medicaid	$2.09
Rate for Payer: AlohaCare Medicare	$1.76
Rate for Payer: Cash Price	$2.72
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.85
Rate for Payer: Devoted Health Medicare	$1.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1.76
Rate for Payer: Hawaii Western Management Group Commercial	$3.97
Rate for Payer: Health Management Network Commercial	$3.55
Rate for Payer: Humana Medicare	$1.76
Rate for Payer: Kaiser Permanente Commercial	$3.76
Rate for Payer: Kaiser Permanente Medicaid	$2.13
Rate for Payer: Kaiser Permanente Medicare	$1.76
Rate for Payer: MDX Hawaii PPO	$4.05
Rate for Payer: Ohana Health Plan Medicaid	$1.76
Rate for Payer: Ohana Health Plan Medicare	$1.76
Rate for Payer: UnitedHealthcare Medicaid	$2.51
Rate for Payer: UnitedHealthcare Medicare	$1.76
Rate for Payer: University Health Alliance Commercial	$3.05

thyroid desiccated 30 mg Tab [KMC]

Facility

$4.18

Service Code	NDC 75834031101
Hospital Revenue Code	250
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$4.05
Rate for Payer: Cash Price	$2.72
Rate for Payer: Health Management Network Commercial	$3.55
Rate for Payer: Kaiser Permanente Commercial	$3.76
Rate for Payer: MDX Hawaii PPO	$4.05

thyroid desiccated 48.75 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 64727330201
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

thyroid desiccated 48.75 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 64727330201
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

thyroid desiccated 60 mg Tab

Facility

$4.64

Service Code	NDC 75834031201
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$4.50
Rate for Payer: Cash Price	$3.02
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: MDX Hawaii PPO	$4.50

thyroid desiccated 60 mg Tab

Facility

$4.64

Service Code	NDC 75834031201
Hospital Revenue Code	250
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$4.50
Rate for Payer: AlohaCare Medicaid	$2.32
Rate for Payer: AlohaCare Medicare	$1.95
Rate for Payer: Cash Price	$3.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.27
Rate for Payer: Devoted Health Medicare	$1.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1.95
Rate for Payer: Hawaii Western Management Group Commercial	$4.41
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Humana Medicare	$1.95
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: Kaiser Permanente Medicaid	$2.37
Rate for Payer: Kaiser Permanente Medicare	$1.95
Rate for Payer: MDX Hawaii PPO	$4.50
Rate for Payer: Ohana Health Plan Medicaid	$1.95
Rate for Payer: Ohana Health Plan Medicare	$1.95
Rate for Payer: UnitedHealthcare Medicaid	$2.78
Rate for Payer: UnitedHealthcare Medicare	$1.95
Rate for Payer: University Health Alliance Commercial	$3.38

Know your out-of-pocket cost for care.

All Charges