Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

DENTAL AND ORAL DISEASES WITH CC

Facility

$19,933.38

Service Code	MSDRG 158
Min. Negotiated Rate	$19,933.38
Max. Negotiated Rate	$19,933.38
Rate for Payer: Hawaii Medical Service Association Commercial	$19,933.38

DENTAL AND ORAL DISEASES WITH MCC

Facility

$19,933.38

Service Code	MSDRG 157
Min. Negotiated Rate	$19,933.38
Max. Negotiated Rate	$19,933.38
Rate for Payer: Hawaii Medical Service Association Commercial	$19,933.38

DENTAL AND ORAL DISEASES WITHOUT CC/MCC

Facility

$19,933.38

Service Code	MSDRG 159
Min. Negotiated Rate	$19,933.38
Max. Negotiated Rate	$19,933.38
Rate for Payer: Hawaii Medical Service Association Commercial	$19,933.38

DEPRESSION SCREEN ANNUAL

Professional

Both

$56.00

Service Code	HCPCS G0444
Hospital Revenue Code	521
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$9.24
Rate for Payer: AlohaCare Medicare	$8.10
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$8.10
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	$13.72
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$9.72
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Ohana Health Plan Medicaid	$9.24
Rate for Payer: Ohana Health Plan Medicare	$8.10
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: University Health Alliance Commercial	$8.98

DEPRESSIVE NEUROSES

Facility

$10,002.24

Service Code	MSDRG 881
Min. Negotiated Rate	$10,002.24
Max. Negotiated Rate	$10,002.24
Rate for Payer: Hawaii Medical Service Association Commercial	$10,002.24

DERMABOND

Facility

$98.00

Hospital Charge Code	8078
Hospital Revenue Code	272
Min. Negotiated Rate	$41.16
Max. Negotiated Rate	$95.06
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$41.16
Rate for Payer: Cash Price	$63.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$90.16
Rate for Payer: Devoted Health Medicare	$41.16
Rate for Payer: Hawaii Medical Service Association Medicare	$41.16
Rate for Payer: Hawaii Western Management Group Commercial	$93.10
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$41.16
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$41.16
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$41.16
Rate for Payer: Ohana Health Plan Medicare	$41.16
Rate for Payer: UnitedHealthcare Medicare	$41.16
Rate for Payer: University Health Alliance Commercial	$71.43

DERMABOND

Facility

$98.00

Hospital Charge Code	8078
Hospital Revenue Code	272
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

desipramine 50 mg Tab [KMC]

Facility

$15.10

Service Code	NDC 50742011401
Hospital Revenue Code	250
Min. Negotiated Rate	$12.84
Max. Negotiated Rate	$14.65
Rate for Payer: Cash Price	$9.82
Rate for Payer: Health Management Network Commercial	$12.84
Rate for Payer: Kaiser Permanente Commercial	$13.59
Rate for Payer: MDX Hawaii PPO	$14.65

desipramine 50 mg Tab [KMC]

Facility

$15.10

Service Code	NDC 50742011401
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$14.65
Rate for Payer: AlohaCare Medicaid	$7.55
Rate for Payer: AlohaCare Medicare	$6.34
Rate for Payer: Cash Price	$9.82
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.89
Rate for Payer: Devoted Health Medicare	$6.34
Rate for Payer: Hawaii Medical Service Association Medicare	$6.34
Rate for Payer: Hawaii Western Management Group Commercial	$14.35
Rate for Payer: Health Management Network Commercial	$12.84
Rate for Payer: Humana Medicare	$6.34
Rate for Payer: Kaiser Permanente Commercial	$13.59
Rate for Payer: Kaiser Permanente Medicaid	$7.70
Rate for Payer: Kaiser Permanente Medicare	$6.34
Rate for Payer: MDX Hawaii PPO	$14.65
Rate for Payer: Ohana Health Plan Medicaid	$6.34
Rate for Payer: Ohana Health Plan Medicare	$6.34
Rate for Payer: UnitedHealthcare Medicaid	$9.06
Rate for Payer: UnitedHealthcare Medicare	$6.34
Rate for Payer: University Health Alliance Commercial	$11.01

desmopressin 0.1 mg Tab [KMC]

Facility

$21.14

Service Code	NDC 23155048901
Hospital Revenue Code	250
Min. Negotiated Rate	$8.88
Max. Negotiated Rate	$20.51
Rate for Payer: AlohaCare Medicaid	$10.57
Rate for Payer: AlohaCare Medicare	$8.88
Rate for Payer: Cash Price	$13.74
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$19.45
Rate for Payer: Devoted Health Medicare	$8.88
Rate for Payer: Hawaii Medical Service Association Medicare	$8.88
Rate for Payer: Hawaii Western Management Group Commercial	$20.08
Rate for Payer: Health Management Network Commercial	$17.97
Rate for Payer: Humana Medicare	$8.88
Rate for Payer: Kaiser Permanente Commercial	$19.03
Rate for Payer: Kaiser Permanente Medicaid	$10.78
Rate for Payer: Kaiser Permanente Medicare	$8.88
Rate for Payer: MDX Hawaii PPO	$20.51
Rate for Payer: Ohana Health Plan Medicaid	$8.88
Rate for Payer: Ohana Health Plan Medicare	$8.88
Rate for Payer: UnitedHealthcare Medicaid	$12.68
Rate for Payer: UnitedHealthcare Medicare	$8.88
Rate for Payer: University Health Alliance Commercial	$15.41

desmopressin 0.1 mg Tab [KMC]

Facility

$21.14

Service Code	NDC 23155048901
Hospital Revenue Code	250
Min. Negotiated Rate	$17.97
Max. Negotiated Rate	$20.51
Rate for Payer: Cash Price	$13.74
Rate for Payer: Health Management Network Commercial	$17.97
Rate for Payer: Kaiser Permanente Commercial	$19.03
Rate for Payer: MDX Hawaii PPO	$20.51

desonide 0.05% Cream [KMC]

Facility

$21.41

Service Code	NDC 16714072901
Hospital Revenue Code	250
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$20.77
Rate for Payer: AlohaCare Medicaid	$10.71
Rate for Payer: AlohaCare Medicare	$8.99
Rate for Payer: Cash Price	$13.92
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$19.70
Rate for Payer: Devoted Health Medicare	$8.99
Rate for Payer: Hawaii Medical Service Association Medicare	$8.99
Rate for Payer: Hawaii Western Management Group Commercial	$20.34
Rate for Payer: Health Management Network Commercial	$18.20
Rate for Payer: Humana Medicare	$8.99
Rate for Payer: Kaiser Permanente Commercial	$19.27
Rate for Payer: Kaiser Permanente Medicaid	$10.92
Rate for Payer: Kaiser Permanente Medicare	$8.99
Rate for Payer: MDX Hawaii PPO	$20.77
Rate for Payer: Ohana Health Plan Medicaid	$8.99
Rate for Payer: Ohana Health Plan Medicare	$8.99
Rate for Payer: UnitedHealthcare Medicaid	$12.85
Rate for Payer: UnitedHealthcare Medicare	$8.99
Rate for Payer: University Health Alliance Commercial	$15.61

desonide 0.05% Cream [KMC]

Facility

$21.41

Service Code	NDC 16714072901
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$20.77
Rate for Payer: Cash Price	$13.92
Rate for Payer: Health Management Network Commercial	$18.20
Rate for Payer: Kaiser Permanente Commercial	$19.27
Rate for Payer: MDX Hawaii PPO	$20.77

desonide 0.05% Ointment [KMC]

Facility

$16.03

Service Code	NDC 51672128103
Hospital Revenue Code	250
Min. Negotiated Rate	$6.73
Max. Negotiated Rate	$15.55
Rate for Payer: AlohaCare Medicaid	$8.02
Rate for Payer: AlohaCare Medicare	$6.73
Rate for Payer: Cash Price	$10.42
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$14.75
Rate for Payer: Devoted Health Medicare	$6.73
Rate for Payer: Hawaii Medical Service Association Medicare	$6.73
Rate for Payer: Hawaii Western Management Group Commercial	$15.23
Rate for Payer: Health Management Network Commercial	$13.63
Rate for Payer: Humana Medicare	$6.73
Rate for Payer: Kaiser Permanente Commercial	$14.43
Rate for Payer: Kaiser Permanente Medicaid	$8.18
Rate for Payer: Kaiser Permanente Medicare	$6.73
Rate for Payer: MDX Hawaii PPO	$15.55
Rate for Payer: Ohana Health Plan Medicaid	$6.73
Rate for Payer: Ohana Health Plan Medicare	$6.73
Rate for Payer: UnitedHealthcare Medicaid	$9.62
Rate for Payer: UnitedHealthcare Medicare	$6.73
Rate for Payer: University Health Alliance Commercial	$11.68

desonide 0.05% Ointment [KMC]

Facility

$16.03

Service Code	NDC 51672128103
Hospital Revenue Code	250
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$15.55
Rate for Payer: Cash Price	$10.42
Rate for Payer: Health Management Network Commercial	$13.63
Rate for Payer: Kaiser Permanente Commercial	$14.43
Rate for Payer: MDX Hawaii PPO	$15.55

desoximetasone 0.25% Cream [KMC]

Facility

$13.14

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.17
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$8.54
Rate for Payer: Health Management Network Commercial	$11.17
Rate for Payer: Kaiser Permanente Commercial	$11.83
Rate for Payer: MDX Hawaii PPO	$12.75

desoximetasone 0.25% Cream [KMC]

Facility

$13.14

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$5.52
Max. Negotiated Rate	$12.75
Rate for Payer: AlohaCare Medicaid	$6.57
Rate for Payer: AlohaCare Medicare	$5.52
Rate for Payer: Cash Price	$8.54
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.09
Rate for Payer: Devoted Health Medicare	$5.52
Rate for Payer: Hawaii Medical Service Association Medicare	$5.52
Rate for Payer: Hawaii Western Management Group Commercial	$12.48
Rate for Payer: Health Management Network Commercial	$11.17
Rate for Payer: Humana Medicare	$5.52
Rate for Payer: Kaiser Permanente Commercial	$11.83
Rate for Payer: Kaiser Permanente Medicaid	$6.70
Rate for Payer: Kaiser Permanente Medicare	$5.52
Rate for Payer: MDX Hawaii PPO	$12.75
Rate for Payer: Ohana Health Plan Medicaid	$5.52
Rate for Payer: Ohana Health Plan Medicare	$5.52
Rate for Payer: UnitedHealthcare Medicare	$5.52
Rate for Payer: University Health Alliance Commercial	$9.58

DESTRUCTION BENIGN LESIONS 15/>

Professional

Both

$254.00

Service Code	HCPCS 17111
Hospital Revenue Code	361
Min. Negotiated Rate	$62.66
Max. Negotiated Rate	$215.90
Rate for Payer: AlohaCare Medicaid	$89.23
Rate for Payer: AlohaCare Medicare	$78.09
Rate for Payer: Cash Price	$165.10
Rate for Payer: Cash Price	$165.10
Rate for Payer: Devoted Health Medicare	$78.09
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$89.23
Rate for Payer: Hawaii Medical Service Association Commercial	$132.09
Rate for Payer: Hawaii Medical Service Association Medicare	$78.09
Rate for Payer: Hawaii Western Management Group Commercial	$62.66
Rate for Payer: Health Management Network Commercial	$215.90
Rate for Payer: Kaiser Permanente Commercial	$93.71
Rate for Payer: Kaiser Permanente Medicaid	$93.71
Rate for Payer: Kaiser Permanente Medicare	$93.71
Rate for Payer: Ohana Health Plan Medicaid	$89.23
Rate for Payer: Ohana Health Plan Medicare	$78.09
Rate for Payer: UnitedHealthcare Medicaid	$89.23
Rate for Payer: UnitedHealthcare Medicare	$78.09
Rate for Payer: University Health Alliance Commercial	$97.90

DESTRUCTION BENIGN LESIONS UP TO 14

Professional

Both

$335.00

Service Code	HCPCS 17110
Hospital Revenue Code	361
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$284.75
Rate for Payer: AlohaCare Medicaid	$74.33
Rate for Payer: AlohaCare Medicare	$66.60
Rate for Payer: Cash Price	$217.75
Rate for Payer: Cash Price	$217.75
Rate for Payer: Devoted Health Medicare	$66.60
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$74.33
Rate for Payer: Hawaii Medical Service Association Commercial	$108.92
Rate for Payer: Hawaii Medical Service Association Medicare	$66.60
Rate for Payer: Hawaii Western Management Group Commercial	$44.20
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Kaiser Permanente Commercial	$79.92
Rate for Payer: Kaiser Permanente Medicaid	$79.92
Rate for Payer: Kaiser Permanente Medicare	$79.92
Rate for Payer: Ohana Health Plan Medicaid	$74.33
Rate for Payer: Ohana Health Plan Medicare	$66.60
Rate for Payer: UnitedHealthcare Medicaid	$74.33
Rate for Payer: UnitedHealthcare Medicare	$66.60
Rate for Payer: University Health Alliance Commercial	$81.21

DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG

Professional

Both

$962.00

Service Code	HCPCS 64624
Hospital Revenue Code	361
Min. Negotiated Rate	$136.26
Max. Negotiated Rate	$817.70
Rate for Payer: AlohaCare Medicaid	$149.86
Rate for Payer: AlohaCare Medicare	$136.26
Rate for Payer: Cash Price	$625.30
Rate for Payer: Cash Price	$625.30
Rate for Payer: Devoted Health Medicare	$136.26
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$149.86
Rate for Payer: Hawaii Medical Service Association Commercial	$231.45
Rate for Payer: Hawaii Medical Service Association Medicare	$136.26
Rate for Payer: Hawaii Western Management Group Commercial	$460.98
Rate for Payer: Health Management Network Commercial	$817.70
Rate for Payer: Kaiser Permanente Commercial	$163.51
Rate for Payer: Kaiser Permanente Medicaid	$163.51
Rate for Payer: Kaiser Permanente Medicare	$163.51
Rate for Payer: Ohana Health Plan Medicaid	$149.86
Rate for Payer: Ohana Health Plan Medicare	$136.26
Rate for Payer: UnitedHealthcare Medicaid	$149.86
Rate for Payer: UnitedHealthcare Medicare	$136.26
Rate for Payer: University Health Alliance Commercial	$195.96

desvenlafaxine 50 mg ER Tab [KMC]

Facility

$47.80

Service Code	NDC 00054040022
Hospital Revenue Code	250
Min. Negotiated Rate	$40.63
Max. Negotiated Rate	$46.37
Rate for Payer: Cash Price	$31.07
Rate for Payer: Health Management Network Commercial	$40.63
Rate for Payer: Kaiser Permanente Commercial	$43.02
Rate for Payer: MDX Hawaii PPO	$46.37

desvenlafaxine 50 mg ER Tab [KMC]

Facility

$47.80

Service Code	NDC 00054040022
Hospital Revenue Code	250
Min. Negotiated Rate	$20.08
Max. Negotiated Rate	$46.37
Rate for Payer: AlohaCare Medicaid	$23.90
Rate for Payer: AlohaCare Medicare	$20.08
Rate for Payer: Cash Price	$31.07
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$43.98
Rate for Payer: Devoted Health Medicare	$20.08
Rate for Payer: Hawaii Medical Service Association Medicare	$20.08
Rate for Payer: Hawaii Western Management Group Commercial	$45.41
Rate for Payer: Health Management Network Commercial	$40.63
Rate for Payer: Humana Medicare	$20.08
Rate for Payer: Kaiser Permanente Commercial	$43.02
Rate for Payer: Kaiser Permanente Medicaid	$24.38
Rate for Payer: Kaiser Permanente Medicare	$20.08
Rate for Payer: MDX Hawaii PPO	$46.37
Rate for Payer: Ohana Health Plan Medicaid	$20.08
Rate for Payer: Ohana Health Plan Medicare	$20.08
Rate for Payer: UnitedHealthcare Medicaid	$28.68
Rate for Payer: UnitedHealthcare Medicare	$20.08
Rate for Payer: University Health Alliance Commercial	$34.84

deutetrabenazine 24 mg ER Tab [KMC]

Facility

$1,132.91

Service Code	NDC 68546047256
Hospital Revenue Code	250
Min. Negotiated Rate	$475.82
Max. Negotiated Rate	$1,098.92
Rate for Payer: AlohaCare Medicaid	$566.46
Rate for Payer: AlohaCare Medicare	$475.82
Rate for Payer: Cash Price	$736.39
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,042.28
Rate for Payer: Devoted Health Medicare	$475.82
Rate for Payer: Hawaii Medical Service Association Medicare	$475.82
Rate for Payer: Hawaii Western Management Group Commercial	$1,076.26
Rate for Payer: Health Management Network Commercial	$962.97
Rate for Payer: Humana Medicare	$475.82
Rate for Payer: Kaiser Permanente Commercial	$1,019.62
Rate for Payer: Kaiser Permanente Medicaid	$577.78
Rate for Payer: Kaiser Permanente Medicare	$475.82
Rate for Payer: MDX Hawaii PPO	$1,098.92
Rate for Payer: Ohana Health Plan Medicaid	$475.82
Rate for Payer: Ohana Health Plan Medicare	$475.82
Rate for Payer: UnitedHealthcare Medicaid	$679.75
Rate for Payer: UnitedHealthcare Medicare	$475.82
Rate for Payer: University Health Alliance Commercial	$825.78

deutetrabenazine 24 mg ER Tab [KMC]

Facility

$1,132.91

Service Code	NDC 68546047256
Hospital Revenue Code	250
Min. Negotiated Rate	$962.97
Max. Negotiated Rate	$1,098.92
Rate for Payer: Cash Price	$736.39
Rate for Payer: Health Management Network Commercial	$962.97
Rate for Payer: Kaiser Permanente Commercial	$1,019.62
Rate for Payer: MDX Hawaii PPO	$1,098.92

DEVELOPMENT OF COGNITIVE SKILLS EACH 15 MINUTES

Professional

Both

$162.00

Service Code	HCPCS 97532
Hospital Revenue Code	430
Min. Negotiated Rate	$24.84
Max. Negotiated Rate	$137.70
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Hawaii Western Management Group Commercial	$24.84
Rate for Payer: Health Management Network Commercial	$137.70

Know your out-of-pocket cost for care.

All Charges