Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

UNLISTED CT SCAN

Facility

$615.00

Service Code	HCPCS 76497
Hospital Charge Code	424764970
Hospital Revenue Code	352
Min. Negotiated Rate	$66.04
Max. Negotiated Rate	$596.55
Rate for Payer: AlohaCare Medicaid	$307.50
Rate for Payer: AlohaCare Medicare	$258.30
Rate for Payer: Cash Price	$399.75
Rate for Payer: Cash Price	$399.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$565.80
Rate for Payer: Devoted Health Medicare	$258.30
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$258.30
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$522.75
Rate for Payer: Humana Medicare	$258.30
Rate for Payer: Kaiser Permanente Commercial	$553.50
Rate for Payer: Kaiser Permanente Medicaid	$313.65
Rate for Payer: Kaiser Permanente Medicare	$258.30
Rate for Payer: MDX Hawaii PPO	$596.55
Rate for Payer: Ohana Health Plan Medicaid	$258.30
Rate for Payer: Ohana Health Plan Medicare	$258.30
Rate for Payer: UnitedHealthcare Medicaid	$66.04
Rate for Payer: UnitedHealthcare Medicare	$258.30
Rate for Payer: University Health Alliance Commercial	$448.27

UNLISTED CT SCAN

Facility

$615.00

Service Code	HCPCS 76497
Hospital Charge Code	424764970
Hospital Revenue Code	352
Min. Negotiated Rate	$522.75
Max. Negotiated Rate	$596.55
Rate for Payer: Cash Price	$399.75
Rate for Payer: Health Management Network Commercial	$522.75
Rate for Payer: Kaiser Permanente Commercial	$553.50
Rate for Payer: MDX Hawaii PPO	$596.55

UNLISTED EVALUATION AND MANAGEMENT SERVICE

Professional

Both

$21.00

Service Code	HCPCS 99499
Hospital Revenue Code	521
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$32.99
Rate for Payer: Cash Price	$13.65
Rate for Payer: Cash Price	$13.65
Rate for Payer: Cash Price	$13.65
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$21.86
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$32.99
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

Unlisted Modality Charge

Facility

$189.00

Service Code	HCPCS 97039 GO
Hospital Charge Code	426970390
Hospital Revenue Code	430
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$122.85
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: MDX Hawaii PPO	$183.33

Unlisted Modality Charge

Facility

$189.00

Service Code	HCPCS 97039 GO
Hospital Charge Code	426970390
Hospital Revenue Code	430
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$183.33
Rate for Payer: AlohaCare Medicaid	$94.50
Rate for Payer: AlohaCare Medicare	$79.38
Rate for Payer: Cash Price	$122.85
Rate for Payer: Cash Price	$122.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$173.88
Rate for Payer: Devoted Health Medicare	$79.38
Rate for Payer: Hawaii Medical Service Association Medicare	$79.38
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Humana Medicare	$79.38
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: Kaiser Permanente Medicare	$79.38
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: Ohana Health Plan Medicaid	$79.38
Rate for Payer: Ohana Health Plan Medicare	$79.38
Rate for Payer: UnitedHealthcare Medicaid	$10.37
Rate for Payer: UnitedHealthcare Medicare	$79.38
Rate for Payer: University Health Alliance Commercial	$137.76

UNLISTED MODALITY Occupational

Facility

$189.00

Service Code	HCPCS 97039 GO
Hospital Charge Code	426970390
Hospital Revenue Code	430
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$183.33
Rate for Payer: AlohaCare Medicaid	$94.50
Rate for Payer: AlohaCare Medicare	$79.38
Rate for Payer: Cash Price	$122.85
Rate for Payer: Cash Price	$122.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$173.88
Rate for Payer: Devoted Health Medicare	$79.38
Rate for Payer: Hawaii Medical Service Association Medicare	$79.38
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Humana Medicare	$79.38
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: Kaiser Permanente Medicare	$79.38
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: Ohana Health Plan Medicaid	$79.38
Rate for Payer: Ohana Health Plan Medicare	$79.38
Rate for Payer: UnitedHealthcare Medicaid	$10.37
Rate for Payer: UnitedHealthcare Medicare	$79.38
Rate for Payer: University Health Alliance Commercial	$137.76

UNLISTED MODALITY Occupational

Facility

$189.00

Service Code	HCPCS 97039 GO
Hospital Charge Code	426970390
Hospital Revenue Code	430
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$122.85
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: MDX Hawaii PPO	$183.33

UNLISTED MODALITY Physical

Facility

$189.00

Service Code	HCPCS 97039 GP
Hospital Charge Code	432970390
Hospital Revenue Code	420
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$122.85
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: MDX Hawaii PPO	$183.33

UNLISTED MODALITY Physical

Facility

$189.00

Service Code	HCPCS 97039 GP
Hospital Charge Code	432970390
Hospital Revenue Code	420
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$183.33
Rate for Payer: AlohaCare Medicaid	$94.50
Rate for Payer: AlohaCare Medicare	$79.38
Rate for Payer: Cash Price	$122.85
Rate for Payer: Cash Price	$122.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$173.88
Rate for Payer: Devoted Health Medicare	$79.38
Rate for Payer: Hawaii Medical Service Association Medicare	$79.38
Rate for Payer: Hawaii Western Management Group Commercial	$179.55
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Humana Medicare	$79.38
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: Kaiser Permanente Medicare	$79.38
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: Ohana Health Plan Medicaid	$79.38
Rate for Payer: Ohana Health Plan Medicare	$79.38
Rate for Payer: UnitedHealthcare Medicaid	$10.37
Rate for Payer: UnitedHealthcare Medicare	$79.38
Rate for Payer: University Health Alliance Commercial	$137.76

UNLISTED MODALITY SPEC TYPE&TIME CONSTANT ATTN

Professional

Both

$180.00

Service Code	HCPCS 97039
Hospital Revenue Code	420
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$153.00
Rate for Payer: AlohaCare Medicaid	$10.37
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Hawaii Western Management Group Commercial	$15.53
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Ohana Health Plan Medicaid	$10.37
Rate for Payer: UnitedHealthcare Medicaid	$10.37

UNLISTED OT E&M SVC Occupational

Facility

$66.00

Service Code	HCPCS 99499 GO
Hospital Charge Code	432994990
Hospital Revenue Code	430
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$27.72
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$60.72
Rate for Payer: Devoted Health Medicare	$27.72
Rate for Payer: Hawaii Medical Service Association Medicare	$27.72
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$27.72
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$27.72
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$27.72
Rate for Payer: Ohana Health Plan Medicare	$27.72
Rate for Payer: UnitedHealthcare Medicaid	$32.99
Rate for Payer: UnitedHealthcare Medicare	$27.72
Rate for Payer: University Health Alliance Commercial	$48.11

UNLISTED OT E&M SVC Occupational

Facility

$66.00

Service Code	HCPCS 99499 GO
Hospital Charge Code	432994990
Hospital Revenue Code	430
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

UNLISTED OTORHINOLARYNGOLOGICAL SERVICE/PX

Professional

Both

$166.00

Service Code	HCPCS 92700
Hospital Revenue Code	440
Min. Negotiated Rate	$141.10
Max. Negotiated Rate	$141.10
Rate for Payer: Cash Price	$107.90
Rate for Payer: Health Management Network Commercial	$141.10

UNLISTED PROCEDURE Physical

Facility

$179.00

Service Code	HCPCS 97139 GP
Hospital Charge Code	432971390
Hospital Revenue Code	420
Min. Negotiated Rate	$12.02
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	$12.02
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

UNLISTED PROCEDURE Physical

Facility

$179.00

Service Code	HCPCS 97139 GP
Hospital Charge Code	432971390
Hospital Revenue Code	420
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

UNLISTED PT E&M SVC Physical

Facility

$23.00

Service Code	HCPCS 99499 GP
Hospital Charge Code	432994990
Hospital Revenue Code	420
Min. Negotiated Rate	$9.66
Max. Negotiated Rate	$32.99
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$9.66
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.16
Rate for Payer: Devoted Health Medicare	$9.66
Rate for Payer: Hawaii Medical Service Association Medicare	$9.66
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$9.66
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$9.66
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$9.66
Rate for Payer: Ohana Health Plan Medicare	$9.66
Rate for Payer: UnitedHealthcare Medicaid	$32.99
Rate for Payer: UnitedHealthcare Medicare	$9.66
Rate for Payer: University Health Alliance Commercial	$16.76

UNLISTED PT E&M SVC Physical

Facility

$23.00

Service Code	HCPCS 99499 GP
Hospital Charge Code	432994990
Hospital Revenue Code	420
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

UNLISTED SPEECH E&M SVC Speech

Facility

$23.00

Service Code	HCPCS 99499 GN
Hospital Charge Code	432994990
Hospital Revenue Code	440
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$14.95
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: MDX Hawaii PPO	$22.31

UNLISTED SPEECH E&M SVC Speech

Facility

$23.00

Service Code	HCPCS 99499 GN
Hospital Charge Code	432994990
Hospital Revenue Code	440
Min. Negotiated Rate	$9.66
Max. Negotiated Rate	$32.99
Rate for Payer: AlohaCare Medicaid	$11.50
Rate for Payer: AlohaCare Medicare	$9.66
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$21.16
Rate for Payer: Devoted Health Medicare	$9.66
Rate for Payer: Hawaii Medical Service Association Medicare	$9.66
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Humana Medicare	$9.66
Rate for Payer: Kaiser Permanente Commercial	$20.70
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: Kaiser Permanente Medicare	$9.66
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: Ohana Health Plan Medicaid	$9.66
Rate for Payer: Ohana Health Plan Medicare	$9.66
Rate for Payer: UnitedHealthcare Medicaid	$32.99
Rate for Payer: UnitedHealthcare Medicare	$9.66
Rate for Payer: University Health Alliance Commercial	$16.76

UNLISTED THERAPEUTIC PROCEDURE SPECIFY

Professional

Both

$162.00

Service Code	HCPCS 97139
Hospital Revenue Code	420
Min. Negotiated Rate	$12.02
Max. Negotiated Rate	$137.70
Rate for Payer: AlohaCare Medicaid	$12.02
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Hawaii Western Management Group Commercial	$13.23
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Ohana Health Plan Medicaid	$12.02
Rate for Payer: UnitedHealthcare Medicaid	$12.02

UNLISTED ULTRASOUND PROC

Facility

$462.00

Service Code	HCPCS 76999
Hospital Charge Code	424769990
Hospital Revenue Code	402
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$448.14
Rate for Payer: Cash Price	$300.30
Rate for Payer: Health Management Network Commercial	$392.70
Rate for Payer: Kaiser Permanente Commercial	$415.80
Rate for Payer: MDX Hawaii PPO	$448.14

UNLISTED ULTRASOUND PROC

Facility

$462.00

Service Code	HCPCS 76999
Hospital Charge Code	424769990
Hospital Revenue Code	402
Min. Negotiated Rate	$66.04
Max. Negotiated Rate	$448.14
Rate for Payer: AlohaCare Medicaid	$231.00
Rate for Payer: AlohaCare Medicare	$194.04
Rate for Payer: Cash Price	$300.30
Rate for Payer: Cash Price	$300.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$425.04
Rate for Payer: Devoted Health Medicare	$194.04
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$194.04
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$392.70
Rate for Payer: Humana Medicare	$194.04
Rate for Payer: Kaiser Permanente Commercial	$415.80
Rate for Payer: Kaiser Permanente Medicaid	$235.62
Rate for Payer: Kaiser Permanente Medicare	$194.04
Rate for Payer: MDX Hawaii PPO	$448.14
Rate for Payer: Ohana Health Plan Medicaid	$194.04
Rate for Payer: Ohana Health Plan Medicare	$194.04
Rate for Payer: UnitedHealthcare Medicaid	$66.04
Rate for Payer: UnitedHealthcare Medicare	$194.04
Rate for Payer: University Health Alliance Commercial	$336.75

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$36,643.29

Service Code	MSDRG 256
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$36,643.29

Service Code	MSDRG 255
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$36,643.29

Service Code	MSDRG 257
Min. Negotiated Rate	$36,643.29
Max. Negotiated Rate	$36,643.29
Rate for Payer: Hawaii Medical Service Association Commercial	$36,643.29

Know your out-of-pocket cost for care.

All Charges