Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

CLSD TX STRN/CLAV DISLC W/MAN Charge

Facility

$887.00

Service Code	HCPCS 23525
Hospital Charge Code	440235250
Hospital Revenue Code	450
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$576.55
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

CLS TRT TALOTRSL DISLOC REQ ANES, PRO FEE

Facility

$554.00

Service Code	HCPCS 28605
Hospital Charge Code	440286050
Hospital Revenue Code	450
Min. Negotiated Rate	$470.90
Max. Negotiated Rate	$537.38
Rate for Payer: Cash Price	$360.10
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: MDX Hawaii PPO	$537.38

CLS TRT TALOTRSL DISLOC REQ ANES, PRO FEE

Facility

$554.00

Service Code	HCPCS 28605
Hospital Charge Code	440286050
Hospital Revenue Code	450
Min. Negotiated Rate	$232.68
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$277.00
Rate for Payer: AlohaCare Medicare	$232.68
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$509.68
Rate for Payer: Devoted Health Medicare	$232.68
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	$232.68
Rate for Payer: Hawaii Western Management Group Commercial	$526.30
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Humana Medicare	$232.68
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$232.68
Rate for Payer: MDX Hawaii PPO	$537.38
Rate for Payer: Ohana Health Plan Medicaid	$232.68
Rate for Payer: Ohana Health Plan Medicare	$232.68
Rate for Payer: UnitedHealthcare Medicare	$232.68
Rate for Payer: University Health Alliance Commercial	$403.81

CL TX MONTEGGIA ELB FX W MANIP ED Charge

Facility

$6,394.00

Service Code	HCPCS 24620
Hospital Charge Code	440246200
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$6,202.18
Rate for Payer: AlohaCare Medicaid	$3,197.00
Rate for Payer: AlohaCare Medicare	$2,685.48
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,882.48
Rate for Payer: Devoted Health Medicare	$2,685.48
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	$2,685.48
Rate for Payer: Hawaii Western Management Group Commercial	$6,074.30
Rate for Payer: Health Management Network Commercial	$5,434.90
Rate for Payer: Humana Medicare	$2,685.48
Rate for Payer: Kaiser Permanente Commercial	$5,754.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,685.48
Rate for Payer: MDX Hawaii PPO	$6,202.18
Rate for Payer: Ohana Health Plan Medicaid	$2,685.48
Rate for Payer: Ohana Health Plan Medicare	$2,685.48
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,685.48
Rate for Payer: University Health Alliance Commercial	$4,035.20

CL TX MONTEGGIA ELB FX W MANIP ED Charge

Facility

$6,394.00

Service Code	HCPCS 24620
Hospital Charge Code	440246200
Hospital Revenue Code	450
Min. Negotiated Rate	$5,434.90
Max. Negotiated Rate	$6,202.18
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Health Management Network Commercial	$5,434.90
Rate for Payer: Kaiser Permanente Commercial	$5,754.60
Rate for Payer: MDX Hawaii PPO	$6,202.18

CL TX PATELLAR DISLOC; W ANEST Charge

Facility

$2,294.00

Service Code	HCPCS 27562
Hospital Charge Code	440275620
Hospital Revenue Code	450
Min. Negotiated Rate	$1,949.90
Max. Negotiated Rate	$2,225.18
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Health Management Network Commercial	$1,949.90
Rate for Payer: Kaiser Permanente Commercial	$2,064.60
Rate for Payer: MDX Hawaii PPO	$2,225.18

CL TX PATELLAR DISLOC; W ANEST Charge

Facility

$2,294.00

Service Code	HCPCS 27562
Hospital Charge Code	440275620
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,147.00
Rate for Payer: AlohaCare Medicare	$963.48
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,110.48
Rate for Payer: Devoted Health Medicare	$963.48
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	$963.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,179.30
Rate for Payer: Health Management Network Commercial	$1,949.90
Rate for Payer: Humana Medicare	$963.48
Rate for Payer: Kaiser Permanente Commercial	$2,064.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$963.48
Rate for Payer: MDX Hawaii PPO	$2,225.18
Rate for Payer: Ohana Health Plan Medicaid	$963.48
Rate for Payer: Ohana Health Plan Medicare	$963.48
Rate for Payer: UnitedHealthcare Medicare	$963.48
Rate for Payer: University Health Alliance Commercial	$4,035.20

CLVCL COMP

Facility

$369.00

Service Code	HCPCS 73000
Hospital Charge Code	424730000
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

CLVCL COMP

Facility

$369.00

Service Code	HCPCS 73000
Hospital Charge Code	424730000
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
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	$17.04
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	$17.04
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$56.28

CMPLX SUTURE, 2.6-7.5CM CHARGE

Facility

$2,091.00

Service Code	HCPCS 13121
Hospital Charge Code	440131210
Hospital Revenue Code	450
Min. Negotiated Rate	$1,777.35
Max. Negotiated Rate	$2,028.27
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: MDX Hawaii PPO	$2,028.27

CMPLX SUTURE, 2.6-7.5CM CHARGE

Facility

$2,091.00

Service Code	HCPCS 13121
Hospital Charge Code	440131210
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,045.50
Rate for Payer: AlohaCare Medicare	$878.22
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,923.72
Rate for Payer: Devoted Health Medicare	$878.22
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	$878.22
Rate for Payer: Hawaii Western Management Group Commercial	$1,986.45
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Humana Medicare	$878.22
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$878.22
Rate for Payer: MDX Hawaii PPO	$2,028.27
Rate for Payer: Ohana Health Plan Medicaid	$878.22
Rate for Payer: Ohana Health Plan Medicare	$878.22
Rate for Payer: UnitedHealthcare Medicare	$878.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

CMPLX SUTURE, EA ADDTL 5CM CHARGE

Facility

$1,358.00

Service Code	HCPCS 13122
Hospital Charge Code	440131220
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$679.00
Rate for Payer: AlohaCare Medicare	$570.36
Rate for Payer: Cash Price	$882.70
Rate for Payer: Cash Price	$882.70
Rate for Payer: Cash Price	$882.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,249.36
Rate for Payer: Devoted Health Medicare	$570.36
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	$570.36
Rate for Payer: Hawaii Western Management Group Commercial	$1,290.10
Rate for Payer: Health Management Network Commercial	$1,154.30
Rate for Payer: Humana Medicare	$570.36
Rate for Payer: Kaiser Permanente Commercial	$1,222.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$570.36
Rate for Payer: MDX Hawaii PPO	$1,317.26
Rate for Payer: Ohana Health Plan Medicaid	$570.36
Rate for Payer: Ohana Health Plan Medicare	$570.36
Rate for Payer: UnitedHealthcare Medicare	$570.36
Rate for Payer: University Health Alliance Commercial	$989.85

CMPLX SUTURE, EA ADDTL 5CM CHARGE

Facility

$1,358.00

Service Code	HCPCS 13122
Hospital Charge Code	440131220
Hospital Revenue Code	450
Min. Negotiated Rate	$1,154.30
Max. Negotiated Rate	$1,317.26
Rate for Payer: Cash Price	$882.70
Rate for Payer: Health Management Network Commercial	$1,154.30
Rate for Payer: Kaiser Permanente Commercial	$1,222.20
Rate for Payer: MDX Hawaii PPO	$1,317.26

CMV DLS

Facility

$173.00

Service Code	HCPCS 86645
Hospital Charge Code	4228664455
Hospital Revenue Code	302
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicare	$72.66
Rate for Payer: Cash Price	$112.45
Rate for Payer: Cash Price	$112.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$159.16
Rate for Payer: Devoted Health Medicare	$72.66
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$23.28
Rate for Payer: Hawaii Medical Service Association Commercial	$21.06
Rate for Payer: Hawaii Medical Service Association Medicare	$72.66
Rate for Payer: Hawaii Western Management Group Commercial	$16.85
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$72.66
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$72.66
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$72.66
Rate for Payer: Ohana Health Plan Medicare	$72.66
Rate for Payer: UnitedHealthcare Medicaid	$23.28
Rate for Payer: UnitedHealthcare Medicare	$72.66
Rate for Payer: University Health Alliance Commercial	$43.55

CMV DLS

Facility

$173.00

Service Code	HCPCS 86645
Hospital Charge Code	4228664455
Hospital Revenue Code	302
Min. Negotiated Rate	$147.05
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$112.45
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$167.81

CO2 DETECTOR ADULT

Facility

$6.00

Hospital Charge Code	8067
Hospital Revenue Code	270
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

CO2 DETECTOR ADULT

Facility

$6.00

Hospital Charge Code	8067
Hospital Revenue Code	270
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

CO2 DETECTOR PEDIATRIC

Facility

$4.00

Hospital Charge Code	8068
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

CO2 DETECTOR PEDIATRIC

Facility

$4.00

Hospital Charge Code	8068
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

COAGULATION DISORDERS

Facility

$32,258.42

Service Code	MSDRG 813
Min. Negotiated Rate	$32,258.42
Max. Negotiated Rate	$32,258.42
Rate for Payer: Hawaii Medical Service Association Commercial	$32,258.42

cobicistat/darunavir/emtric/tenofovir 150-800-200-10 mg Tab

Facility

$754.71

Service Code	NDC 59676080030
Hospital Revenue Code	250
Min. Negotiated Rate	$316.98
Max. Negotiated Rate	$732.07
Rate for Payer: AlohaCare Medicaid	$377.36
Rate for Payer: AlohaCare Medicare	$316.98
Rate for Payer: Cash Price	$490.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$694.33
Rate for Payer: Devoted Health Medicare	$316.98
Rate for Payer: Hawaii Medical Service Association Medicare	$316.98
Rate for Payer: Hawaii Western Management Group Commercial	$716.97
Rate for Payer: Health Management Network Commercial	$641.50
Rate for Payer: Humana Medicare	$316.98
Rate for Payer: Kaiser Permanente Commercial	$679.24
Rate for Payer: Kaiser Permanente Medicaid	$384.90
Rate for Payer: Kaiser Permanente Medicare	$316.98
Rate for Payer: MDX Hawaii PPO	$732.07
Rate for Payer: Ohana Health Plan Medicaid	$316.98
Rate for Payer: Ohana Health Plan Medicare	$316.98
Rate for Payer: UnitedHealthcare Medicaid	$452.83
Rate for Payer: UnitedHealthcare Medicare	$316.98
Rate for Payer: University Health Alliance Commercial	$550.11

cobicistat/darunavir/emtric/tenofovir 150-800-200-10 mg Tab

Facility

$754.71

Service Code	NDC 59676080030
Hospital Revenue Code	250
Min. Negotiated Rate	$641.50
Max. Negotiated Rate	$732.07
Rate for Payer: Cash Price	$490.56
Rate for Payer: Health Management Network Commercial	$641.50
Rate for Payer: Kaiser Permanente Commercial	$679.24
Rate for Payer: MDX Hawaii PPO	$732.07

cobicistat-elvitegravir-emtricitabine-tenofov 150-150-200-10mg Tab

Facility

$518.13

Service Code	NDC 61958190101
Hospital Revenue Code	250
Min. Negotiated Rate	$440.41
Max. Negotiated Rate	$502.59
Rate for Payer: Cash Price	$336.78
Rate for Payer: Health Management Network Commercial	$440.41
Rate for Payer: Kaiser Permanente Commercial	$466.32
Rate for Payer: MDX Hawaii PPO	$502.59

cobicistat-elvitegravir-emtricitabine-tenofov 150-150-200-10mg Tab

Facility

$518.13

Service Code	NDC 61958190101
Hospital Revenue Code	250
Min. Negotiated Rate	$217.61
Max. Negotiated Rate	$502.59
Rate for Payer: AlohaCare Medicaid	$259.06
Rate for Payer: AlohaCare Medicare	$217.61
Rate for Payer: Cash Price	$336.78
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$476.68
Rate for Payer: Devoted Health Medicare	$217.61
Rate for Payer: Hawaii Medical Service Association Medicare	$217.61
Rate for Payer: Hawaii Western Management Group Commercial	$492.22
Rate for Payer: Health Management Network Commercial	$440.41
Rate for Payer: Humana Medicare	$217.61
Rate for Payer: Kaiser Permanente Commercial	$466.32
Rate for Payer: Kaiser Permanente Medicaid	$264.25
Rate for Payer: Kaiser Permanente Medicare	$217.61
Rate for Payer: MDX Hawaii PPO	$502.59
Rate for Payer: Ohana Health Plan Medicaid	$217.61
Rate for Payer: Ohana Health Plan Medicare	$217.61
Rate for Payer: UnitedHealthcare Medicaid	$310.88
Rate for Payer: UnitedHealthcare Medicare	$217.61
Rate for Payer: University Health Alliance Commercial	$377.66

codeine-guaiFENesin 10-100mg/5mL Oral Syrup [KMC]

Facility

$0.40

Service Code	NDC 69367027216
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.26
Rate for Payer: Health Management Network Commercial	$0.34
Rate for Payer: Kaiser Permanente Commercial	$0.36
Rate for Payer: MDX Hawaii PPO	$0.39

Know your out-of-pocket cost for care.

All Charges