Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD

Facility

$205.69

Service Code	NDC 58160081011
Hospital Revenue Code	250
Min. Negotiated Rate	$174.84
Max. Negotiated Rate	$199.52
Rate for Payer: Cash Price	$133.70
Rate for Payer: Health Management Network Commercial	$174.84
Rate for Payer: Kaiser Permanente Commercial	$185.12
Rate for Payer: MDX Hawaii PPO	$199.52

diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD

Facility

$205.69

Service Code	NDC 58160081011
Hospital Revenue Code	250
Min. Negotiated Rate	$86.39
Max. Negotiated Rate	$199.52
Rate for Payer: AlohaCare Medicaid	$102.84
Rate for Payer: AlohaCare Medicare	$86.39
Rate for Payer: Cash Price	$133.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$189.23
Rate for Payer: Devoted Health Medicare	$86.39
Rate for Payer: Hawaii Medical Service Association Medicare	$86.39
Rate for Payer: Hawaii Western Management Group Commercial	$195.41
Rate for Payer: Health Management Network Commercial	$174.84
Rate for Payer: Humana Medicare	$86.39
Rate for Payer: Kaiser Permanente Commercial	$185.12
Rate for Payer: Kaiser Permanente Medicaid	$104.90
Rate for Payer: Kaiser Permanente Medicare	$86.39
Rate for Payer: MDX Hawaii PPO	$199.52
Rate for Payer: Ohana Health Plan Medicaid	$86.39
Rate for Payer: Ohana Health Plan Medicare	$86.39
Rate for Payer: UnitedHealthcare Medicaid	$123.41
Rate for Payer: UnitedHealthcare Medicare	$86.39
Rate for Payer: University Health Alliance Commercial	$149.93

diphtheria/tetanus/pertussis (DTaP) Pediatric 0.5 mL vial [KMC]

Facility

$312.00

Service Code	HCPCS 90700
Hospital Revenue Code	637
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$202.80
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: MDX Hawaii PPO	$302.64

diphtheria/tetanus/pertussis (DTaP) Pediatric 0.5 mL vial [KMC]

Facility

$312.00

Service Code	HCPCS 90700
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$302.64
Rate for Payer: AlohaCare Medicaid	$156.00
Rate for Payer: AlohaCare Medicare	$131.04
Rate for Payer: Cash Price	$202.80
Rate for Payer: Cash Price	$202.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$287.04
Rate for Payer: Devoted Health Medicare	$131.04
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$32.42
Rate for Payer: Hawaii Medical Service Association Medicare	$131.04
Rate for Payer: Hawaii Western Management Group Commercial	$296.40
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Humana Medicare	$131.04
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: Kaiser Permanente Medicare	$131.04
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: Ohana Health Plan Medicaid	$131.04
Rate for Payer: Ohana Health Plan Medicare	$131.04
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$131.04
Rate for Payer: University Health Alliance Commercial	$227.42

diphth/haemophilus/pertussis/tetanus/polio - Kit

Facility

$416.91

Service Code	NDC 49281051005
Hospital Revenue Code	250
Min. Negotiated Rate	$175.10
Max. Negotiated Rate	$404.40
Rate for Payer: AlohaCare Medicaid	$208.46
Rate for Payer: AlohaCare Medicare	$175.10
Rate for Payer: Cash Price	$270.99
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$383.56
Rate for Payer: Devoted Health Medicare	$175.10
Rate for Payer: Hawaii Medical Service Association Medicare	$175.10
Rate for Payer: Hawaii Western Management Group Commercial	$396.06
Rate for Payer: Health Management Network Commercial	$354.37
Rate for Payer: Humana Medicare	$175.10
Rate for Payer: Kaiser Permanente Commercial	$375.22
Rate for Payer: Kaiser Permanente Medicaid	$212.62
Rate for Payer: Kaiser Permanente Medicare	$175.10
Rate for Payer: MDX Hawaii PPO	$404.40
Rate for Payer: Ohana Health Plan Medicaid	$175.10
Rate for Payer: Ohana Health Plan Medicare	$175.10
Rate for Payer: UnitedHealthcare Medicaid	$250.15
Rate for Payer: UnitedHealthcare Medicare	$175.10
Rate for Payer: University Health Alliance Commercial	$303.89

diphth/haemophilus/pertussis/tetanus/polio - Kit

Facility

$416.91

Service Code	NDC 49281051005
Hospital Revenue Code	250
Min. Negotiated Rate	$354.37
Max. Negotiated Rate	$404.40
Rate for Payer: Cash Price	$270.99
Rate for Payer: Health Management Network Commercial	$354.37
Rate for Payer: Kaiser Permanente Commercial	$375.22
Rate for Payer: MDX Hawaii PPO	$404.40

DIPHTH TETANUS TOX ACELL PERTUSSIS (INFANRIX) VACC<7 YR IM

Professional

Both

$0.01

Service Code	HCPCS 90700 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$31.13
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$31.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

DIPHTH TETANUS TOX ACELL PERTUSSIS (INFANRIX) VACC<7 YR IM

Professional

Both

$109.00

Service Code	HCPCS 90700
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$92.65
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Hawaii Western Management Group Commercial	$31.13
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

Direct Coombs

Facility

$204.00

Service Code	HCPCS 86880
Hospital Charge Code	422868800
Hospital Revenue Code	302
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: MDX Hawaii PPO	$197.88

Direct Coombs

Facility

$204.00

Service Code	HCPCS 86880
Hospital Charge Code	422868800
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$197.88
Rate for Payer: AlohaCare Medicaid	$102.00
Rate for Payer: AlohaCare Medicare	$85.68
Rate for Payer: Cash Price	$132.60
Rate for Payer: Cash Price	$132.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$187.68
Rate for Payer: Devoted Health Medicare	$85.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.42
Rate for Payer: Hawaii Medical Service Association Commercial	$6.74
Rate for Payer: Hawaii Medical Service Association Medicare	$85.68
Rate for Payer: Hawaii Western Management Group Commercial	$5.39
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Humana Medicare	$85.68
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicare	$85.68
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: Ohana Health Plan Medicaid	$85.68
Rate for Payer: Ohana Health Plan Medicare	$85.68
Rate for Payer: UnitedHealthcare Medicaid	$7.42
Rate for Payer: UnitedHealthcare Medicare	$85.68
Rate for Payer: University Health Alliance Commercial	$13.88

Direct LDL

Facility

$506.00

Service Code	HCPCS 83721
Hospital Charge Code	422837210
Hospital Revenue Code	301
Min. Negotiated Rate	$430.10
Max. Negotiated Rate	$490.82
Rate for Payer: Cash Price	$328.90
Rate for Payer: Health Management Network Commercial	$430.10
Rate for Payer: Kaiser Permanente Commercial	$455.40
Rate for Payer: MDX Hawaii PPO	$490.82

Direct LDL

Facility

$506.00

Service Code	HCPCS 83721
Hospital Charge Code	422837210
Hospital Revenue Code	301
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$490.82
Rate for Payer: AlohaCare Medicaid	$253.00
Rate for Payer: AlohaCare Medicare	$212.52
Rate for Payer: Cash Price	$328.90
Rate for Payer: Cash Price	$328.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$465.52
Rate for Payer: Devoted Health Medicare	$212.52
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$13.18
Rate for Payer: Hawaii Medical Service Association Commercial	$13.12
Rate for Payer: Hawaii Medical Service Association Medicare	$212.52
Rate for Payer: Hawaii Western Management Group Commercial	$10.50
Rate for Payer: Health Management Network Commercial	$430.10
Rate for Payer: Humana Medicare	$212.52
Rate for Payer: Kaiser Permanente Commercial	$455.40
Rate for Payer: Kaiser Permanente Medicaid	$258.06
Rate for Payer: Kaiser Permanente Medicare	$212.52
Rate for Payer: MDX Hawaii PPO	$490.82
Rate for Payer: Ohana Health Plan Medicaid	$212.52
Rate for Payer: Ohana Health Plan Medicare	$212.52
Rate for Payer: UnitedHealthcare Medicaid	$13.18
Rate for Payer: UnitedHealthcare Medicare	$212.52
Rate for Payer: University Health Alliance Commercial	$24.66

DISCHRG MEDS RECONCILED W/CURRENT MED LIST

Professional

Both

$0.01

Service Code	HCPCS 1111F
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	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
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

DISLOCATION OF TOE W/O ANESTHESIA CHARGE

Facility

$887.00

Service Code	HCPCS 28630
Hospital Charge Code	440286300
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

DISLOCATION OF TOE W/O ANESTHESIA CHARGE

Facility

$887.00

Service Code	HCPCS 28630
Hospital Charge Code	440286300
Hospital Revenue Code	450
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$372.54
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$816.04
Rate for Payer: Devoted Health Medicare	$372.54
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	$372.54
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$372.54
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$372.54
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$372.54
Rate for Payer: Ohana Health Plan Medicare	$372.54
Rate for Payer: UnitedHealthcare Medicare	$372.54
Rate for Payer: University Health Alliance Commercial	$646.53

DISLOC CLSD IP JOINT W/O ANE Charge

Facility

$554.00

Service Code	HCPCS 28660
Hospital Charge Code	440286600
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

DISLOC CLSD IP JOINT W/O ANE Charge

Facility

$554.00

Service Code	HCPCS 28660
Hospital Charge Code	440286600
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

DISLOC TX HIP W/O ANESTHESIA Charge

Facility

$887.00

Service Code	HCPCS 27250
Hospital Charge Code	440272500
Hospital Revenue Code	450
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$372.54
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$816.04
Rate for Payer: Devoted Health Medicare	$372.54
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	$372.54
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$372.54
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$372.54
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$372.54
Rate for Payer: Ohana Health Plan Medicare	$372.54
Rate for Payer: UnitedHealthcare Medicare	$372.54
Rate for Payer: University Health Alliance Commercial	$646.53

DISLOC TX HIP W/O ANESTHESIA Charge

Facility

$887.00

Service Code	HCPCS 27250
Hospital Charge Code	440272500
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

DIS METACARPOPHLANGEAL W/WO FI Charge

Facility

$10,275.00

Service Code	HCPCS 26715
Hospital Charge Code	440267150
Hospital Revenue Code	450
Min. Negotiated Rate	$8,733.75
Max. Negotiated Rate	$9,966.75
Rate for Payer: Cash Price	$6,678.75
Rate for Payer: Health Management Network Commercial	$8,733.75
Rate for Payer: Kaiser Permanente Commercial	$9,247.50
Rate for Payer: MDX Hawaii PPO	$9,966.75

DIS METACARPOPHLANGEAL W/WO FI Charge

Facility

$10,275.00

Service Code	HCPCS 26715
Hospital Charge Code	440267150
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$5,137.50
Rate for Payer: AlohaCare Medicare	$4,315.50
Rate for Payer: Cash Price	$6,678.75
Rate for Payer: Cash Price	$6,678.75
Rate for Payer: Cash Price	$6,678.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9,453.00
Rate for Payer: Devoted Health Medicare	$4,315.50
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	$4,315.50
Rate for Payer: Hawaii Western Management Group Commercial	$9,761.25
Rate for Payer: Health Management Network Commercial	$8,733.75
Rate for Payer: Humana Medicare	$4,315.50
Rate for Payer: Kaiser Permanente Commercial	$9,247.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,315.50
Rate for Payer: MDX Hawaii PPO	$9,966.75
Rate for Payer: Ohana Health Plan Medicaid	$4,315.50
Rate for Payer: Ohana Health Plan Medicare	$4,315.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,315.50
Rate for Payer: University Health Alliance Commercial	$10,679.55

DIS MODFY ANTI-RHEU DRUG THXPY RX/GVN

Professional

Both

$0.01

Service Code	HCPCS 4187F
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	$273.13
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$31,926.59

Service Code	MSDRG 442
Min. Negotiated Rate	$31,926.59
Max. Negotiated Rate	$31,926.59
Rate for Payer: Hawaii Medical Service Association Commercial	$31,926.59

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$31,926.59

Service Code	MSDRG 441
Min. Negotiated Rate	$31,926.59
Max. Negotiated Rate	$31,926.59
Rate for Payer: Hawaii Medical Service Association Commercial	$31,926.59

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$23,085.75

Service Code	MSDRG 443
Min. Negotiated Rate	$23,085.75
Max. Negotiated Rate	$23,085.75
Rate for Payer: Hawaii Medical Service Association Commercial	$23,085.75

Know your out-of-pocket cost for care.

All Charges