Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC

Facility

$24,958.21

Service Code	MSDRG 439
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC

Facility

$24,958.21

Service Code	MSDRG 438
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC

Facility

$24,958.21

Service Code	MSDRG 440
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility

$21,118.48

Service Code	MSDRG 883
Min. Negotiated Rate	$21,118.48
Max. Negotiated Rate	$21,118.48
Rate for Payer: Hawaii Medical Service Association Commercial	$21,118.48

DISORDERS OF THE BILIARY TRACT WITH CC

Facility

$25,124.12

Service Code	MSDRG 445
Min. Negotiated Rate	$25,124.12
Max. Negotiated Rate	$25,124.12
Rate for Payer: Hawaii Medical Service Association Commercial	$25,124.12

DISORDERS OF THE BILIARY TRACT WITH MCC

Facility

$25,645.56

Service Code	MSDRG 444
Min. Negotiated Rate	$25,645.56
Max. Negotiated Rate	$25,645.56
Rate for Payer: Hawaii Medical Service Association Commercial	$25,645.56

DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC

Facility

$16,567.70

Service Code	MSDRG 446
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

DISPOSIBLE CHEST TUBE KIT

Facility

$56.00

Hospital Charge Code	8083
Hospital Revenue Code	272
Min. Negotiated Rate	$23.52
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$23.52
Rate for Payer: Cash Price	$36.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$51.52
Rate for Payer: Devoted Health Medicare	$23.52
Rate for Payer: Hawaii Medical Service Association Medicare	$23.52
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$23.52
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$23.52
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$23.52
Rate for Payer: Ohana Health Plan Medicare	$23.52
Rate for Payer: UnitedHealthcare Medicare	$23.52
Rate for Payer: University Health Alliance Commercial	$40.82

DISPOSIBLE CHEST TUBE KIT

Facility

$56.00

Hospital Charge Code	8083
Hospital Revenue Code	272
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

DISPOSIBLE DIGITAL THERMOMETERS

Facility

$4.00

Hospital Charge Code	8084
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

DISPOSIBLE DIGITAL THERMOMETERS

Facility

$4.00

Hospital Charge Code	8084
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

divalproex 500 mg DR Tab [KMC]

Facility

$3.00

Service Code	NDC 00904686161
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

divalproex 500 mg DR Tab [KMC]

Facility

$3.00

Service Code	NDC 00904686161
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

divalproex sodium 125 mg DR cap [KMC]

Facility

$8.13

Service Code	NDC 00074611413
Hospital Revenue Code	250
Min. Negotiated Rate	$6.91
Max. Negotiated Rate	$7.89
Rate for Payer: Cash Price	$5.28
Rate for Payer: Health Management Network Commercial	$6.91
Rate for Payer: Kaiser Permanente Commercial	$7.32
Rate for Payer: MDX Hawaii PPO	$7.89

divalproex sodium 125 mg DR cap [KMC]

Facility

$8.13

Service Code	NDC 00074611413
Hospital Revenue Code	250
Min. Negotiated Rate	$3.41
Max. Negotiated Rate	$7.89
Rate for Payer: AlohaCare Medicaid	$4.07
Rate for Payer: AlohaCare Medicare	$3.41
Rate for Payer: Cash Price	$5.28
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.48
Rate for Payer: Devoted Health Medicare	$3.41
Rate for Payer: Hawaii Medical Service Association Medicare	$3.41
Rate for Payer: Hawaii Western Management Group Commercial	$7.72
Rate for Payer: Health Management Network Commercial	$6.91
Rate for Payer: Humana Medicare	$3.41
Rate for Payer: Kaiser Permanente Commercial	$7.32
Rate for Payer: Kaiser Permanente Medicaid	$4.15
Rate for Payer: Kaiser Permanente Medicare	$3.41
Rate for Payer: MDX Hawaii PPO	$7.89
Rate for Payer: Ohana Health Plan Medicaid	$3.41
Rate for Payer: Ohana Health Plan Medicare	$3.41
Rate for Payer: UnitedHealthcare Medicaid	$4.88
Rate for Payer: UnitedHealthcare Medicare	$3.41
Rate for Payer: University Health Alliance Commercial	$5.93

divalproex sodium 250 mg DR tablet [KMC]

Facility

$7.05

Service Code	NDC 29300013901
Hospital Revenue Code	250
Min. Negotiated Rate	$5.99
Max. Negotiated Rate	$6.84
Rate for Payer: Cash Price	$4.58
Rate for Payer: Health Management Network Commercial	$5.99
Rate for Payer: Kaiser Permanente Commercial	$6.34
Rate for Payer: MDX Hawaii PPO	$6.84

divalproex sodium 250 mg DR tablet [KMC]

Facility

$7.05

Service Code	NDC 29300013901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$6.84
Rate for Payer: AlohaCare Medicaid	$3.52
Rate for Payer: AlohaCare Medicare	$2.96
Rate for Payer: Cash Price	$4.58
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.49
Rate for Payer: Devoted Health Medicare	$2.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2.96
Rate for Payer: Hawaii Western Management Group Commercial	$6.70
Rate for Payer: Health Management Network Commercial	$5.99
Rate for Payer: Humana Medicare	$2.96
Rate for Payer: Kaiser Permanente Commercial	$6.34
Rate for Payer: Kaiser Permanente Medicaid	$3.60
Rate for Payer: Kaiser Permanente Medicare	$2.96
Rate for Payer: MDX Hawaii PPO	$6.84
Rate for Payer: Ohana Health Plan Medicaid	$2.96
Rate for Payer: Ohana Health Plan Medicare	$2.96
Rate for Payer: UnitedHealthcare Medicaid	$4.23
Rate for Payer: UnitedHealthcare Medicare	$2.96
Rate for Payer: University Health Alliance Commercial	$5.14

divalproex sodium 250 mg ER Tab [KMC]

Facility

$9.82

Service Code	NDC 00378047201
Hospital Revenue Code	250
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$9.53
Rate for Payer: AlohaCare Medicaid	$4.91
Rate for Payer: AlohaCare Medicare	$4.12
Rate for Payer: Cash Price	$6.38
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.03
Rate for Payer: Devoted Health Medicare	$4.12
Rate for Payer: Hawaii Medical Service Association Medicare	$4.12
Rate for Payer: Hawaii Western Management Group Commercial	$9.33
Rate for Payer: Health Management Network Commercial	$8.35
Rate for Payer: Humana Medicare	$4.12
Rate for Payer: Kaiser Permanente Commercial	$8.84
Rate for Payer: Kaiser Permanente Medicaid	$5.01
Rate for Payer: Kaiser Permanente Medicare	$4.12
Rate for Payer: MDX Hawaii PPO	$9.53
Rate for Payer: Ohana Health Plan Medicaid	$4.12
Rate for Payer: Ohana Health Plan Medicare	$4.12
Rate for Payer: UnitedHealthcare Medicaid	$5.89
Rate for Payer: UnitedHealthcare Medicare	$4.12
Rate for Payer: University Health Alliance Commercial	$7.16

divalproex sodium 250 mg ER Tab [KMC]

Facility

$9.82

Service Code	NDC 00378047201
Hospital Revenue Code	250
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$9.53
Rate for Payer: Cash Price	$6.38
Rate for Payer: Health Management Network Commercial	$8.35
Rate for Payer: Kaiser Permanente Commercial	$8.84
Rate for Payer: MDX Hawaii PPO	$9.53

divalproex sodium 500 mg ER tab [KMC]

Facility

$16.30

Service Code	NDC 16714048501
Hospital Revenue Code	250
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$15.81
Rate for Payer: AlohaCare Medicaid	$8.15
Rate for Payer: AlohaCare Medicare	$6.85
Rate for Payer: Cash Price	$10.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.00
Rate for Payer: Devoted Health Medicare	$6.85
Rate for Payer: Hawaii Medical Service Association Medicare	$6.85
Rate for Payer: Hawaii Western Management Group Commercial	$15.48
Rate for Payer: Health Management Network Commercial	$13.86
Rate for Payer: Humana Medicare	$6.85
Rate for Payer: Kaiser Permanente Commercial	$14.67
Rate for Payer: Kaiser Permanente Medicaid	$8.31
Rate for Payer: Kaiser Permanente Medicare	$6.85
Rate for Payer: MDX Hawaii PPO	$15.81
Rate for Payer: Ohana Health Plan Medicaid	$6.85
Rate for Payer: Ohana Health Plan Medicare	$6.85
Rate for Payer: UnitedHealthcare Medicaid	$9.78
Rate for Payer: UnitedHealthcare Medicare	$6.85
Rate for Payer: University Health Alliance Commercial	$11.88

divalproex sodium 500 mg ER tab [KMC]

Facility

$16.30

Service Code	NDC 16714048501
Hospital Revenue Code	250
Min. Negotiated Rate	$13.86
Max. Negotiated Rate	$15.81
Rate for Payer: Cash Price	$10.60
Rate for Payer: Health Management Network Commercial	$13.86
Rate for Payer: Kaiser Permanente Commercial	$14.67
Rate for Payer: MDX Hawaii PPO	$15.81

DOC OF NON TOBACCO USER

Professional

Both

$0.01

Service Code	HCPCS G9275
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

docosanol (Abreva) 10% Cream [KMC]

Facility

$37.10

Service Code	NDC 00135020001
Hospital Revenue Code	250
Min. Negotiated Rate	$31.54
Max. Negotiated Rate	$35.99
Rate for Payer: Cash Price	$24.12
Rate for Payer: Health Management Network Commercial	$31.54
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: MDX Hawaii PPO	$35.99

docosanol (Abreva) 10% Cream [KMC]

Facility

$37.10

Service Code	NDC 00135020001
Hospital Revenue Code	250
Min. Negotiated Rate	$15.58
Max. Negotiated Rate	$35.99
Rate for Payer: AlohaCare Medicaid	$18.55
Rate for Payer: AlohaCare Medicare	$15.58
Rate for Payer: Cash Price	$24.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$34.13
Rate for Payer: Devoted Health Medicare	$15.58
Rate for Payer: Hawaii Medical Service Association Medicare	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$35.24
Rate for Payer: Health Management Network Commercial	$31.54
Rate for Payer: Humana Medicare	$15.58
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: Kaiser Permanente Medicaid	$18.92
Rate for Payer: Kaiser Permanente Medicare	$15.58
Rate for Payer: MDX Hawaii PPO	$35.99
Rate for Payer: Ohana Health Plan Medicaid	$15.58
Rate for Payer: Ohana Health Plan Medicare	$15.58
Rate for Payer: UnitedHealthcare Medicaid	$22.26
Rate for Payer: UnitedHealthcare Medicare	$15.58
Rate for Payer: University Health Alliance Commercial	$27.04

DOCUMENTATION OF TREATMENT FOR NEPHROPATHY

Professional

Both

$0.01

Service Code	HCPCS 3066F
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

Know your out-of-pocket cost for care.

All Charges