Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

cetirizine 5 mg / 5 mL oral syrup [KMC]

Facility

$0.42

Service Code	NDC 50580073005
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.41
Rate for Payer: AlohaCare Medicaid	$0.21
Rate for Payer: AlohaCare Medicare	$0.18
Rate for Payer: Cash Price	$0.27
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.39
Rate for Payer: Devoted Health Medicare	$0.18
Rate for Payer: Hawaii Medical Service Association Medicare	$0.18
Rate for Payer: Hawaii Western Management Group Commercial	$0.40
Rate for Payer: Health Management Network Commercial	$0.36
Rate for Payer: Humana Medicare	$0.18
Rate for Payer: Kaiser Permanente Commercial	$0.38
Rate for Payer: Kaiser Permanente Medicaid	$0.21
Rate for Payer: Kaiser Permanente Medicare	$0.18
Rate for Payer: MDX Hawaii PPO	$0.41
Rate for Payer: Ohana Health Plan Medicaid	$0.18
Rate for Payer: Ohana Health Plan Medicare	$0.18
Rate for Payer: UnitedHealthcare Medicaid	$0.25
Rate for Payer: UnitedHealthcare Medicare	$0.18
Rate for Payer: University Health Alliance Commercial	$0.31

cetirizine 5 mg / 5 mL oral syrup [KMC]

Facility

$0.42

Service Code	NDC 50580073005
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.27
Rate for Payer: Health Management Network Commercial	$0.36
Rate for Payer: Kaiser Permanente Commercial	$0.38
Rate for Payer: MDX Hawaii PPO	$0.41

cevimeline 30 mg Cap [KMC]

Facility

$13.94

Service Code	NDC 59651042201
Hospital Revenue Code	250
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$13.52
Rate for Payer: AlohaCare Medicaid	$6.97
Rate for Payer: AlohaCare Medicare	$5.85
Rate for Payer: Cash Price	$9.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.82
Rate for Payer: Devoted Health Medicare	$5.85
Rate for Payer: Hawaii Medical Service Association Medicare	$5.85
Rate for Payer: Hawaii Western Management Group Commercial	$13.24
Rate for Payer: Health Management Network Commercial	$11.85
Rate for Payer: Humana Medicare	$5.85
Rate for Payer: Kaiser Permanente Commercial	$12.55
Rate for Payer: Kaiser Permanente Medicaid	$7.11
Rate for Payer: Kaiser Permanente Medicare	$5.85
Rate for Payer: MDX Hawaii PPO	$13.52
Rate for Payer: Ohana Health Plan Medicaid	$5.85
Rate for Payer: Ohana Health Plan Medicare	$5.85
Rate for Payer: UnitedHealthcare Medicaid	$8.36
Rate for Payer: UnitedHealthcare Medicare	$5.85
Rate for Payer: University Health Alliance Commercial	$10.16

cevimeline 30 mg Cap [KMC]

Facility

$13.94

Service Code	NDC 59651042201
Hospital Revenue Code	250
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$13.52
Rate for Payer: Cash Price	$9.06
Rate for Payer: Health Management Network Commercial	$11.85
Rate for Payer: Kaiser Permanente Commercial	$12.55
Rate for Payer: MDX Hawaii PPO	$13.52

CHANGE GASTROSTOMY TUBE CHARGE

Facility

$940.00

Service Code	HCPCS 43760
Hospital Charge Code	440437600
Hospital Revenue Code	450
Min. Negotiated Rate	$394.80
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$470.00
Rate for Payer: AlohaCare Medicare	$394.80
Rate for Payer: Cash Price	$611.00
Rate for Payer: Cash Price	$611.00
Rate for Payer: Cash Price	$611.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$864.80
Rate for Payer: Devoted Health Medicare	$394.80
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	$394.80
Rate for Payer: Hawaii Western Management Group Commercial	$893.00
Rate for Payer: Health Management Network Commercial	$799.00
Rate for Payer: Humana Medicare	$394.80
Rate for Payer: Kaiser Permanente Commercial	$846.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$394.80
Rate for Payer: MDX Hawaii PPO	$911.80
Rate for Payer: Ohana Health Plan Medicaid	$394.80
Rate for Payer: Ohana Health Plan Medicare	$394.80
Rate for Payer: UnitedHealthcare Medicare	$394.80
Rate for Payer: University Health Alliance Commercial	$685.17

CHANGE GASTROSTOMY TUBE CHARGE

Facility

$940.00

Service Code	HCPCS 43760
Hospital Charge Code	440437600
Hospital Revenue Code	450
Min. Negotiated Rate	$799.00
Max. Negotiated Rate	$911.80
Rate for Payer: Cash Price	$611.00
Rate for Payer: Health Management Network Commercial	$799.00
Rate for Payer: Kaiser Permanente Commercial	$846.00
Rate for Payer: MDX Hawaii PPO	$911.80

CHANGE OF CYSTOSTOMY TUBE SIMPLE CHARGE

Facility

$1,080.00

Service Code	HCPCS 51705
Hospital Charge Code	440517050
Hospital Revenue Code	450
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$1,047.60
Rate for Payer: Cash Price	$702.00
Rate for Payer: Health Management Network Commercial	$918.00
Rate for Payer: Kaiser Permanente Commercial	$972.00
Rate for Payer: MDX Hawaii PPO	$1,047.60

CHANGE OF CYSTOSTOMY TUBE SIMPLE CHARGE

Facility

$1,080.00

Service Code	HCPCS 51705
Hospital Charge Code	440517050
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$540.00
Rate for Payer: AlohaCare Medicare	$453.60
Rate for Payer: Cash Price	$702.00
Rate for Payer: Cash Price	$702.00
Rate for Payer: Cash Price	$702.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$993.60
Rate for Payer: Devoted Health Medicare	$453.60
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	$453.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,026.00
Rate for Payer: Health Management Network Commercial	$918.00
Rate for Payer: Humana Medicare	$453.60
Rate for Payer: Kaiser Permanente Commercial	$972.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$453.60
Rate for Payer: MDX Hawaii PPO	$1,047.60
Rate for Payer: Ohana Health Plan Medicaid	$453.60
Rate for Payer: Ohana Health Plan Medicare	$453.60
Rate for Payer: UnitedHealthcare Medicare	$453.60
Rate for Payer: University Health Alliance Commercial	$787.21

charcoal-sorbitol 25 g Oral Susp 120 mL [KMC]

Facility

$0.56

Service Code	NDC 00574012074
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.54
Rate for Payer: AlohaCare Medicaid	$0.28
Rate for Payer: AlohaCare Medicare	$0.24
Rate for Payer: Cash Price	$0.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.52
Rate for Payer: Devoted Health Medicare	$0.24
Rate for Payer: Hawaii Medical Service Association Medicare	$0.24
Rate for Payer: Hawaii Western Management Group Commercial	$0.53
Rate for Payer: Health Management Network Commercial	$0.48
Rate for Payer: Humana Medicare	$0.24
Rate for Payer: Kaiser Permanente Commercial	$0.50
Rate for Payer: Kaiser Permanente Medicaid	$0.29
Rate for Payer: Kaiser Permanente Medicare	$0.24
Rate for Payer: MDX Hawaii PPO	$0.54
Rate for Payer: Ohana Health Plan Medicaid	$0.24
Rate for Payer: Ohana Health Plan Medicare	$0.24
Rate for Payer: UnitedHealthcare Medicaid	$0.34
Rate for Payer: UnitedHealthcare Medicare	$0.24
Rate for Payer: University Health Alliance Commercial	$0.41

charcoal-sorbitol 25 g Oral Susp 120 mL [KMC]

Facility

$0.56

Service Code	NDC 00574012074
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Management Network Commercial	$0.48
Rate for Payer: Kaiser Permanente Commercial	$0.50
Rate for Payer: MDX Hawaii PPO	$0.54

Checkout for Prosth/Orth Use Charges

Facility

$179.00

Service Code	HCPCS 97762 GO
Hospital Charge Code	426977620
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

Checkout for Prosth/Orth Use Charges

Facility

$179.00

Service Code	HCPCS 97762 GO
Hospital Charge Code	426977620
Hospital Revenue Code	430
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

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC

Facility

$57,975.09

Service Code	MSDRG 837
Min. Negotiated Rate	$57,975.09
Max. Negotiated Rate	$57,975.09
Rate for Payer: Hawaii Medical Service Association Commercial	$57,975.09

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT

Facility

$57,975.09

Service Code	MSDRG 838
Min. Negotiated Rate	$57,975.09
Max. Negotiated Rate	$57,975.09
Rate for Payer: Hawaii Medical Service Association Commercial	$57,975.09

CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$57,975.09

Service Code	MSDRG 839
Min. Negotiated Rate	$57,975.09
Max. Negotiated Rate	$57,975.09
Rate for Payer: Hawaii Medical Service Association Commercial	$57,975.09

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC

Facility

$18,511.26

Service Code	MSDRG 847
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC

Facility

$18,511.26

Service Code	MSDRG 846
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$18,511.26

Service Code	MSDRG 848
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEST 2 VWS FRONTAL LATERAL

Facility

$381.00

Service Code	HCPCS 71046
Hospital Charge Code	424710200
Hospital Revenue Code	324
Min. Negotiated Rate	$20.40
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	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$160.02
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
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	$22.29
Rate for Payer: UnitedHealthcare Medicare	$160.02
Rate for Payer: University Health Alliance Commercial	$62.81

CHEST 2 VWS FRONTAL LATERAL

Facility

$381.00

Service Code	HCPCS 71046
Hospital Charge Code	424710200
Hospital Revenue Code	324
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

CHEST COMPLETE 4 VIEWS MIN

Facility

$581.00

Service Code	HCPCS 71048
Hospital Charge Code	424710300
Hospital Revenue Code	324
Min. Negotiated Rate	$493.85
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$377.65
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: MDX Hawaii PPO	$563.57

CHEST COMPLETE 4 VIEWS MIN

Facility

$581.00

Service Code	HCPCS 71048
Hospital Charge Code	424710300
Hospital Revenue Code	324
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$563.57
Rate for Payer: AlohaCare Medicaid	$290.50
Rate for Payer: AlohaCare Medicare	$244.02
Rate for Payer: Cash Price	$377.65
Rate for Payer: Cash Price	$377.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$534.52
Rate for Payer: Devoted Health Medicare	$244.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$25.96
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$244.02
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$493.85
Rate for Payer: Humana Medicare	$244.02
Rate for Payer: Kaiser Permanente Commercial	$522.90
Rate for Payer: Kaiser Permanente Medicaid	$296.31
Rate for Payer: Kaiser Permanente Medicare	$244.02
Rate for Payer: MDX Hawaii PPO	$563.57
Rate for Payer: Ohana Health Plan Medicaid	$244.02
Rate for Payer: Ohana Health Plan Medicare	$244.02
Rate for Payer: UnitedHealthcare Medicaid	$30.28
Rate for Payer: UnitedHealthcare Medicare	$244.02
Rate for Payer: University Health Alliance Commercial	$86.36

CHEST DRAINAGE UNIT

Facility

$4.00

Hospital Charge Code	8057
Hospital Revenue Code	270
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

CHEST DRAINAGE UNIT

Facility

$4.00

Hospital Charge Code	8057
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

CHEST PAIN

Facility

$11,448.07

Service Code	MSDRG 313
Min. Negotiated Rate	$11,448.07
Max. Negotiated Rate	$11,448.07
Rate for Payer: Hawaii Medical Service Association Commercial	$11,448.07

Know your out-of-pocket cost for care.

All Charges