Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$0.40

Service Code	NDC 69367027216
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.39
Rate for Payer: AlohaCare Medicaid	$0.20
Rate for Payer: AlohaCare Medicare	$0.17
Rate for Payer: Cash Price	$0.26
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.37
Rate for Payer: Devoted Health Medicare	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$0.38
Rate for Payer: Health Management Network Commercial	$0.34
Rate for Payer: Humana Medicare	$0.17
Rate for Payer: Kaiser Permanente Commercial	$0.36
Rate for Payer: Kaiser Permanente Medicaid	$0.20
Rate for Payer: Kaiser Permanente Medicare	$0.17
Rate for Payer: MDX Hawaii PPO	$0.39
Rate for Payer: Ohana Health Plan Medicaid	$0.17
Rate for Payer: Ohana Health Plan Medicare	$0.17
Rate for Payer: UnitedHealthcare Medicaid	$0.24
Rate for Payer: UnitedHealthcare Medicare	$0.17
Rate for Payer: University Health Alliance Commercial	$0.29

codeine-promethazine 10-6.25mg/5mL syrup [KMC]

Facility

$0.39

Service Code	NDC 60432060616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: MDX Hawaii PPO	$0.38

codeine-promethazine 10-6.25mg/5mL syrup [KMC]

Facility

$0.39

Service Code	NDC 60432060616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.38
Rate for Payer: AlohaCare Medicaid	$0.20
Rate for Payer: AlohaCare Medicare	$0.16
Rate for Payer: Cash Price	$0.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.36
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$0.37
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Humana Medicare	$0.16
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: Kaiser Permanente Medicaid	$0.20
Rate for Payer: Kaiser Permanente Medicare	$0.16
Rate for Payer: MDX Hawaii PPO	$0.38
Rate for Payer: Ohana Health Plan Medicaid	$0.16
Rate for Payer: Ohana Health Plan Medicare	$0.16
Rate for Payer: UnitedHealthcare Medicaid	$0.23
Rate for Payer: UnitedHealthcare Medicare	$0.16
Rate for Payer: University Health Alliance Commercial	$0.28

COGNITIVE SKILLS DEVELOPMENT

Professional

Both

$154.00

Service Code	HCPCS G0515
Hospital Revenue Code	430
Min. Negotiated Rate	$24.84
Max. Negotiated Rate	$130.90
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Hawaii Western Management Group Commercial	$24.84
Rate for Payer: Health Management Network Commercial	$130.90

colchicine 0.6 mg Tab [KMC]

Facility

$28.79

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$12.09
Max. Negotiated Rate	$27.93
Rate for Payer: AlohaCare Medicaid	$14.39
Rate for Payer: AlohaCare Medicare	$12.09
Rate for Payer: Cash Price	$18.71
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$26.49
Rate for Payer: Devoted Health Medicare	$12.09
Rate for Payer: Hawaii Medical Service Association Medicare	$12.09
Rate for Payer: Hawaii Western Management Group Commercial	$27.35
Rate for Payer: Health Management Network Commercial	$24.47
Rate for Payer: Humana Medicare	$12.09
Rate for Payer: Kaiser Permanente Commercial	$25.91
Rate for Payer: Kaiser Permanente Medicaid	$14.68
Rate for Payer: Kaiser Permanente Medicare	$12.09
Rate for Payer: MDX Hawaii PPO	$27.93
Rate for Payer: Ohana Health Plan Medicaid	$12.09
Rate for Payer: Ohana Health Plan Medicare	$12.09
Rate for Payer: UnitedHealthcare Medicare	$12.09
Rate for Payer: University Health Alliance Commercial	$20.99

colchicine 0.6 mg Tab [KMC]

Facility

$28.79

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$24.47
Max. Negotiated Rate	$27.93
Rate for Payer: Cash Price	$18.71
Rate for Payer: Health Management Network Commercial	$24.47
Rate for Payer: Kaiser Permanente Commercial	$25.91
Rate for Payer: MDX Hawaii PPO	$27.93

COLD PACK

Facility

$69.00

Hospital Charge Code	8069
Hospital Revenue Code	270
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

COLD PACK

Facility

$69.00

Hospital Charge Code	8069
Hospital Revenue Code	270
Min. Negotiated Rate	$28.98
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$50.29

colesevelam 625 mg Tab [KMC]

Facility

$15.82

Service Code	NDC 00713093681
Hospital Revenue Code	250
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$15.35
Rate for Payer: AlohaCare Medicaid	$7.91
Rate for Payer: AlohaCare Medicare	$6.64
Rate for Payer: Cash Price	$10.28
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$14.55
Rate for Payer: Devoted Health Medicare	$6.64
Rate for Payer: Hawaii Medical Service Association Medicare	$6.64
Rate for Payer: Hawaii Western Management Group Commercial	$15.03
Rate for Payer: Health Management Network Commercial	$13.45
Rate for Payer: Humana Medicare	$6.64
Rate for Payer: Kaiser Permanente Commercial	$14.24
Rate for Payer: Kaiser Permanente Medicaid	$8.07
Rate for Payer: Kaiser Permanente Medicare	$6.64
Rate for Payer: MDX Hawaii PPO	$15.35
Rate for Payer: Ohana Health Plan Medicaid	$6.64
Rate for Payer: Ohana Health Plan Medicare	$6.64
Rate for Payer: UnitedHealthcare Medicaid	$9.49
Rate for Payer: UnitedHealthcare Medicare	$6.64
Rate for Payer: University Health Alliance Commercial	$11.53

colesevelam 625 mg Tab [KMC]

Facility

$15.82

Service Code	NDC 00713093681
Hospital Revenue Code	250
Min. Negotiated Rate	$13.45
Max. Negotiated Rate	$15.35
Rate for Payer: Cash Price	$10.28
Rate for Payer: Health Management Network Commercial	$13.45
Rate for Payer: Kaiser Permanente Commercial	$14.24
Rate for Payer: MDX Hawaii PPO	$15.35

collagenase 250 units/gm Ointment [KMC]

Facility

$28.31

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$27.46
Rate for Payer: AlohaCare Medicaid	$14.15
Rate for Payer: AlohaCare Medicare	$11.89
Rate for Payer: Cash Price	$18.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$26.05
Rate for Payer: Devoted Health Medicare	$11.89
Rate for Payer: Hawaii Medical Service Association Medicare	$11.89
Rate for Payer: Hawaii Western Management Group Commercial	$26.89
Rate for Payer: Health Management Network Commercial	$24.06
Rate for Payer: Humana Medicare	$11.89
Rate for Payer: Kaiser Permanente Commercial	$25.48
Rate for Payer: Kaiser Permanente Medicaid	$14.44
Rate for Payer: Kaiser Permanente Medicare	$11.89
Rate for Payer: MDX Hawaii PPO	$27.46
Rate for Payer: Ohana Health Plan Medicaid	$11.89
Rate for Payer: Ohana Health Plan Medicare	$11.89
Rate for Payer: UnitedHealthcare Medicare	$11.89
Rate for Payer: University Health Alliance Commercial	$20.64

collagenase 250 units/gm Ointment [KMC]

Facility

$28.31

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$27.46
Rate for Payer: Cash Price	$18.40
Rate for Payer: Health Management Network Commercial	$24.06
Rate for Payer: Kaiser Permanente Commercial	$25.48
Rate for Payer: MDX Hawaii PPO	$27.46

COLLECTION VENOUS BLOOD VENIPUNCTURE

Professional

Both

$19.00

Service Code	HCPCS 36415
Hospital Revenue Code	300
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$16.15
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$9.34
Rate for Payer: Cash Price	$12.35
Rate for Payer: Cash Price	$12.35
Rate for Payer: Devoted Health Medicare	$9.34
Rate for Payer: Hawaii Medical Service Association Medicare	$9.34
Rate for Payer: Hawaii Western Management Group Commercial	$3.12
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$11.21
Rate for Payer: Kaiser Permanente Medicaid	$11.21
Rate for Payer: Kaiser Permanente Medicare	$11.21
Rate for Payer: Ohana Health Plan Medicaid	$3.00
Rate for Payer: Ohana Health Plan Medicare	$9.34
Rate for Payer: UnitedHealthcare Medicaid	$3.00
Rate for Payer: UnitedHealthcare Medicare	$9.34

COLLES SPLINT LT LG

Facility

$182.00

Hospital Charge Code	8070
Hospital Revenue Code	270
Min. Negotiated Rate	$76.44
Max. Negotiated Rate	$176.54
Rate for Payer: AlohaCare Medicaid	$91.00
Rate for Payer: AlohaCare Medicare	$76.44
Rate for Payer: Cash Price	$118.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$167.44
Rate for Payer: Devoted Health Medicare	$76.44
Rate for Payer: Hawaii Medical Service Association Medicare	$76.44
Rate for Payer: Hawaii Western Management Group Commercial	$172.90
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Humana Medicare	$76.44
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: Kaiser Permanente Medicaid	$92.82
Rate for Payer: Kaiser Permanente Medicare	$76.44
Rate for Payer: MDX Hawaii PPO	$176.54
Rate for Payer: Ohana Health Plan Medicaid	$76.44
Rate for Payer: Ohana Health Plan Medicare	$76.44
Rate for Payer: UnitedHealthcare Medicare	$76.44
Rate for Payer: University Health Alliance Commercial	$132.66

COLLES SPLINT LT LG

Facility

$182.00

Hospital Charge Code	8070
Hospital Revenue Code	270
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$118.30
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: MDX Hawaii PPO	$176.54

COLLES SPLINT LT SM

Facility

$46.00

Hospital Charge Code	8072
Hospital Revenue Code	270
Min. Negotiated Rate	$19.32
Max. Negotiated Rate	$44.62
Rate for Payer: AlohaCare Medicaid	$23.00
Rate for Payer: AlohaCare Medicare	$19.32
Rate for Payer: Cash Price	$29.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$42.32
Rate for Payer: Devoted Health Medicare	$19.32
Rate for Payer: Hawaii Medical Service Association Medicare	$19.32
Rate for Payer: Hawaii Western Management Group Commercial	$43.70
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Humana Medicare	$19.32
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicare	$19.32
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: Ohana Health Plan Medicaid	$19.32
Rate for Payer: Ohana Health Plan Medicare	$19.32
Rate for Payer: UnitedHealthcare Medicare	$19.32
Rate for Payer: University Health Alliance Commercial	$33.53

COLLES SPLINT LT SM

Facility

$46.00

Hospital Charge Code	8072
Hospital Revenue Code	270
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$29.90
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: MDX Hawaii PPO	$44.62

COLLES SPLINT RT LG

Facility

$18.00

Hospital Charge Code	8073
Hospital Revenue Code	270
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$7.56
Rate for Payer: Cash Price	$11.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.56
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$7.56
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$7.56
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$7.56
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$7.56
Rate for Payer: Ohana Health Plan Medicare	$7.56
Rate for Payer: UnitedHealthcare Medicare	$7.56
Rate for Payer: University Health Alliance Commercial	$13.12

COLLES SPLINT RT LG

Facility

$18.00

Hospital Charge Code	8073
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

COLLES SPLINT RT MED

Facility

$18.00

Hospital Charge Code	8074
Hospital Revenue Code	270
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: MDX Hawaii PPO	$17.46

COLLES SPLINT RT MED

Facility

$18.00

Hospital Charge Code	8074
Hospital Revenue Code	270
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$17.46
Rate for Payer: AlohaCare Medicaid	$9.00
Rate for Payer: AlohaCare Medicare	$7.56
Rate for Payer: Cash Price	$11.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$16.56
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Hawaii Medical Service Association Medicare	$7.56
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Humana Medicare	$7.56
Rate for Payer: Kaiser Permanente Commercial	$16.20
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicare	$7.56
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: Ohana Health Plan Medicaid	$7.56
Rate for Payer: Ohana Health Plan Medicare	$7.56
Rate for Payer: UnitedHealthcare Medicare	$7.56
Rate for Payer: University Health Alliance Commercial	$13.12

COLLES SPLINT RT SM

Facility

$46.00

Hospital Charge Code	8075
Hospital Revenue Code	270
Min. Negotiated Rate	$39.10
Max. Negotiated Rate	$44.62
Rate for Payer: Cash Price	$29.90
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: MDX Hawaii PPO	$44.62

COLLES SPLINT RT SM

Facility

$46.00

Hospital Charge Code	8075
Hospital Revenue Code	270
Min. Negotiated Rate	$19.32
Max. Negotiated Rate	$44.62
Rate for Payer: AlohaCare Medicaid	$23.00
Rate for Payer: AlohaCare Medicare	$19.32
Rate for Payer: Cash Price	$29.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$42.32
Rate for Payer: Devoted Health Medicare	$19.32
Rate for Payer: Hawaii Medical Service Association Medicare	$19.32
Rate for Payer: Hawaii Western Management Group Commercial	$43.70
Rate for Payer: Health Management Network Commercial	$39.10
Rate for Payer: Humana Medicare	$19.32
Rate for Payer: Kaiser Permanente Commercial	$41.40
Rate for Payer: Kaiser Permanente Medicaid	$23.46
Rate for Payer: Kaiser Permanente Medicare	$19.32
Rate for Payer: MDX Hawaii PPO	$44.62
Rate for Payer: Ohana Health Plan Medicaid	$19.32
Rate for Payer: Ohana Health Plan Medicare	$19.32
Rate for Payer: UnitedHealthcare Medicare	$19.32
Rate for Payer: University Health Alliance Commercial	$33.53

COLORECTAL CANCER SCREENING RESULTS DOC&REV

Professional

Both

$0.01

Service Code	HCPCS 3017F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
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: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

COLPOSCOPY CERVIX BX CERVIX & ENDOCRV CURRETAGE

Professional

Both

$507.00

Service Code	HCPCS 57454
Hospital Revenue Code	361
Min. Negotiated Rate	$104.78
Max. Negotiated Rate	$430.95
Rate for Payer: AlohaCare Medicaid	$134.18
Rate for Payer: AlohaCare Medicare	$117.36
Rate for Payer: Cash Price	$329.55
Rate for Payer: Cash Price	$329.55
Rate for Payer: Devoted Health Medicare	$117.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$134.18
Rate for Payer: Hawaii Medical Service Association Commercial	$208.80
Rate for Payer: Hawaii Medical Service Association Medicare	$117.36
Rate for Payer: Hawaii Western Management Group Commercial	$104.78
Rate for Payer: Health Management Network Commercial	$430.95
Rate for Payer: Kaiser Permanente Commercial	$140.83
Rate for Payer: Kaiser Permanente Medicaid	$140.83
Rate for Payer: Kaiser Permanente Medicare	$140.83
Rate for Payer: Ohana Health Plan Medicaid	$134.18
Rate for Payer: Ohana Health Plan Medicare	$117.36
Rate for Payer: UnitedHealthcare Medicaid	$134.18
Rate for Payer: UnitedHealthcare Medicare	$117.36
Rate for Payer: University Health Alliance Commercial	$166.07

Know your out-of-pocket cost for care.

All Charges