Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$101,136.43

Service Code	MSDRG 465
Min. Negotiated Rate	$101,136.43
Max. Negotiated Rate	$101,136.43
Rate for Payer: Hawaii Medical Service Association Commercial	$101,136.43

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$28,086.87

Service Code	MSDRG 902
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$28,086.87

Service Code	MSDRG 901
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$28,086.87

Service Code	MSDRG 903
Min. Negotiated Rate	$28,086.87
Max. Negotiated Rate	$28,086.87
Rate for Payer: Hawaii Medical Service Association Commercial	$28,086.87

WOUND VAC

Facility

$1,952.00

Hospital Charge Code	8398
Hospital Revenue Code	290
Min. Negotiated Rate	$819.84
Max. Negotiated Rate	$1,893.44
Rate for Payer: AlohaCare Medicaid	$976.00
Rate for Payer: AlohaCare Medicare	$819.84
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,795.84
Rate for Payer: Devoted Health Medicare	$819.84
Rate for Payer: Hawaii Medical Service Association Medicare	$819.84
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.40
Rate for Payer: Health Management Network Commercial	$1,659.20
Rate for Payer: Humana Medicare	$819.84
Rate for Payer: Kaiser Permanente Commercial	$1,756.80
Rate for Payer: Kaiser Permanente Medicaid	$995.52
Rate for Payer: Kaiser Permanente Medicare	$819.84
Rate for Payer: MDX Hawaii PPO	$1,893.44
Rate for Payer: Ohana Health Plan Medicaid	$819.84
Rate for Payer: Ohana Health Plan Medicare	$819.84
Rate for Payer: UnitedHealthcare Medicare	$819.84
Rate for Payer: University Health Alliance Commercial	$1,422.81

WOUND VAC

Facility

$1,952.00

Hospital Charge Code	8398
Hospital Revenue Code	290
Min. Negotiated Rate	$1,659.20
Max. Negotiated Rate	$1,893.44
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Health Management Network Commercial	$1,659.20
Rate for Payer: Kaiser Permanente Commercial	$1,756.80
Rate for Payer: MDX Hawaii PPO	$1,893.44

Wright Stain

Facility

$72.00

Service Code	HCPCS 87205
Hospital Charge Code	422872050
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$30.24
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$66.24
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$30.24
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$30.24
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$30.24
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$30.24
Rate for Payer: Ohana Health Plan Medicare	$30.24
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$30.24
Rate for Payer: University Health Alliance Commercial	$11.03

Wright Stain

Facility

$72.00

Service Code	HCPCS 87205
Hospital Charge Code	422872050
Hospital Revenue Code	306
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

WRIST 2 VWS

Facility

$369.00

Service Code	HCPCS 73100
Hospital Charge Code	424731000
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

WRIST 2 VWS

Facility

$369.00

Service Code	HCPCS 73100
Hospital Charge Code	424731000
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$57.07

WRIST COMPLETE MIN 3 VWS

Facility

$369.00

Service Code	HCPCS 73110
Hospital Charge Code	424731100
Hospital Revenue Code	320
Min. Negotiated Rate	$17.34
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$17.34
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$17.34
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$66.60

WRIST COMPLETE MIN 3 VWS

Facility

$369.00

Service Code	HCPCS 73110
Hospital Charge Code	424731100
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

WRK HARDENING EA ADDL HR Physical

Facility

$179.00

Service Code	HCPCS 97546 GP
Hospital Charge Code	426975460
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

WRK HARDENING EA ADDL HR Physical

Facility

$179.00

Service Code	HCPCS 97546 GP
Hospital Charge Code	426975460
Hospital Revenue Code	420
Min. Negotiated Rate	$75.18
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: 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 Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

WRK HARDENING INITIAL 2HR Physical

Facility

$296.00

Service Code	HCPCS 97545 GP
Hospital Charge Code	426975450
Hospital Revenue Code	420
Min. Negotiated Rate	$124.32
Max. Negotiated Rate	$287.12
Rate for Payer: AlohaCare Medicaid	$148.00
Rate for Payer: AlohaCare Medicare	$124.32
Rate for Payer: Cash Price	$192.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$272.32
Rate for Payer: Devoted Health Medicare	$124.32
Rate for Payer: Hawaii Medical Service Association Medicare	$124.32
Rate for Payer: Hawaii Western Management Group Commercial	$281.20
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Humana Medicare	$124.32
Rate for Payer: Kaiser Permanente Commercial	$266.40
Rate for Payer: Kaiser Permanente Medicaid	$150.96
Rate for Payer: Kaiser Permanente Medicare	$124.32
Rate for Payer: MDX Hawaii PPO	$287.12
Rate for Payer: Ohana Health Plan Medicaid	$124.32
Rate for Payer: Ohana Health Plan Medicare	$124.32
Rate for Payer: UnitedHealthcare Medicare	$124.32
Rate for Payer: University Health Alliance Commercial	$215.75

WRK HARDENING INITIAL 2HR Physical

Facility

$296.00

Service Code	HCPCS 97545 GP
Hospital Charge Code	426975450
Hospital Revenue Code	420
Min. Negotiated Rate	$251.60
Max. Negotiated Rate	$287.12
Rate for Payer: Cash Price	$192.40
Rate for Payer: Health Management Network Commercial	$251.60
Rate for Payer: Kaiser Permanente Commercial	$266.40
Rate for Payer: MDX Hawaii PPO	$287.12

XEROFORM 1X8

Facility

$2.00

Hospital Charge Code	8391
Hospital Revenue Code	270
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

XEROFORM 1X8

Facility

$2.00

Hospital Charge Code	8391
Hospital Revenue Code	270
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

XEROFORM 5X9

Facility

$5.00

Hospital Charge Code	8392
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

XEROFORM 5X9

Facility

$5.00

Hospital Charge Code	8392
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

X-HIP 2views

Facility

$381.00

Service Code	HCPCS 73521
Hospital Charge Code	424735210
Hospital Revenue Code	320
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$247.65
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: MDX Hawaii PPO	$369.57

X-HIP 2views

Facility

$381.00

Service Code	HCPCS 73521
Hospital Charge Code	424735210
Hospital Revenue Code	320
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$369.57
Rate for Payer: AlohaCare Medicaid	$190.50
Rate for Payer: AlohaCare Medicare	$160.02
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$350.52
Rate for Payer: Devoted Health Medicare	$160.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$19.61
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$160.02
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Humana Medicare	$160.02
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: Kaiser Permanente Medicare	$160.02
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: Ohana Health Plan Medicaid	$160.02
Rate for Payer: Ohana Health Plan Medicare	$160.02
Rate for Payer: UnitedHealthcare Medicaid	$27.57
Rate for Payer: UnitedHealthcare Medicare	$160.02
Rate for Payer: University Health Alliance Commercial	$82.40

X-RAY ABDOMEN 1VIEW

Facility

$371.00

Service Code	HCPCS 74018
Hospital Charge Code	424740180
Hospital Revenue Code	320
Min. Negotiated Rate	$315.35
Max. Negotiated Rate	$359.87
Rate for Payer: Cash Price	$241.15
Rate for Payer: Health Management Network Commercial	$315.35
Rate for Payer: Kaiser Permanente Commercial	$333.90
Rate for Payer: MDX Hawaii PPO	$359.87

X-RAY ABDOMEN 1VIEW

Facility

$371.00

Service Code	HCPCS 74018
Hospital Charge Code	424740180
Hospital Revenue Code	320
Min. Negotiated Rate	$18.74
Max. Negotiated Rate	$359.87
Rate for Payer: AlohaCare Medicaid	$185.50
Rate for Payer: AlohaCare Medicare	$155.82
Rate for Payer: Cash Price	$241.15
Rate for Payer: Cash Price	$241.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$341.32
Rate for Payer: Devoted Health Medicare	$155.82
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.74
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$155.82
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$315.35
Rate for Payer: Humana Medicare	$155.82
Rate for Payer: Kaiser Permanente Commercial	$333.90
Rate for Payer: Kaiser Permanente Medicaid	$189.21
Rate for Payer: Kaiser Permanente Medicare	$155.82
Rate for Payer: MDX Hawaii PPO	$359.87
Rate for Payer: Ohana Health Plan Medicaid	$155.82
Rate for Payer: Ohana Health Plan Medicare	$155.82
Rate for Payer: UnitedHealthcare Medicaid	$20.11
Rate for Payer: UnitedHealthcare Medicare	$155.82
Rate for Payer: University Health Alliance Commercial	$56.31

XR Insert PICC Line less than 5 Year

Facility

$4,339.00

Service Code	HCPCS 36568
Hospital Charge Code	440365680
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,208.83
Rate for Payer: AlohaCare Medicaid	$2,169.50
Rate for Payer: AlohaCare Medicare	$1,822.38
Rate for Payer: Cash Price	$2,820.35
Rate for Payer: Cash Price	$2,820.35
Rate for Payer: Cash Price	$2,820.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3,991.88
Rate for Payer: Devoted Health Medicare	$1,822.38
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,822.38
Rate for Payer: Hawaii Western Management Group Commercial	$4,122.05
Rate for Payer: Health Management Network Commercial	$3,688.15
Rate for Payer: Humana Medicare	$1,822.38
Rate for Payer: Kaiser Permanente Commercial	$3,905.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,822.38
Rate for Payer: MDX Hawaii PPO	$4,208.83
Rate for Payer: Ohana Health Plan Medicaid	$1,822.38
Rate for Payer: Ohana Health Plan Medicare	$1,822.38
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,822.38
Rate for Payer: University Health Alliance Commercial	$3,162.70

Know your out-of-pocket cost for care.

All Charges