Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$16,923.23

Service Code	MSDRG 391
Min. Negotiated Rate	$16,923.23
Max. Negotiated Rate	$16,923.23
Rate for Payer: Hawaii Medical Service Association Commercial	$16,923.23

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$14,553.03

Service Code	MSDRG 392
Min. Negotiated Rate	$14,553.03
Max. Negotiated Rate	$14,553.03
Rate for Payer: Hawaii Medical Service Association Commercial	$14,553.03

E-STIM MANUAL EA 15 MIN Occupational

Facility

$179.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	426970320
Hospital Revenue Code	430
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

E-STIM MANUAL EA 15 MIN Occupational

Facility

$179.00

Service Code	HCPCS 97032 GO
Hospital Charge Code	426970320
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

E-STIM MANUAL EA 15 MIN Physical

Facility

$179.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	432970320
Hospital Revenue Code	420
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

E-STIM MANUAL EA 15 MIN Physical

Facility

$179.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	432970320
Hospital Revenue Code	420
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

E-STIM UNATTENDED Occupational

Facility

$70.00

Service Code	HCPCS G0281 GO
Hospital Charge Code	426G02810
Hospital Revenue Code	420
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$67.90
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: MDX Hawaii PPO	$67.90

E-STIM UNATTENDED Occupational

Facility

$70.00

Service Code	HCPCS G0281 GO
Hospital Charge Code	426G02810
Hospital Revenue Code	420
Min. Negotiated Rate	$9.73
Max. Negotiated Rate	$67.90
Rate for Payer: AlohaCare Medicaid	$35.00
Rate for Payer: AlohaCare Medicare	$29.40
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$64.40
Rate for Payer: Devoted Health Medicare	$29.40
Rate for Payer: Hawaii Medical Service Association Medicare	$29.40
Rate for Payer: Hawaii Western Management Group Commercial	$66.50
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Humana Medicare	$29.40
Rate for Payer: Kaiser Permanente Commercial	$63.00
Rate for Payer: Kaiser Permanente Medicaid	$35.70
Rate for Payer: Kaiser Permanente Medicare	$29.40
Rate for Payer: MDX Hawaii PPO	$67.90
Rate for Payer: Ohana Health Plan Medicaid	$29.40
Rate for Payer: Ohana Health Plan Medicare	$29.40
Rate for Payer: UnitedHealthcare Medicaid	$9.73
Rate for Payer: UnitedHealthcare Medicare	$29.40
Rate for Payer: University Health Alliance Commercial	$51.02

E-STIM UNATTENDED Physical

Facility

$167.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	426970140
Hospital Revenue Code	421
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$161.99
Rate for Payer: AlohaCare Medicaid	$83.50
Rate for Payer: AlohaCare Medicare	$70.14
Rate for Payer: Cash Price	$108.55
Rate for Payer: Cash Price	$108.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$153.64
Rate for Payer: Devoted Health Medicare	$70.14
Rate for Payer: Hawaii Medical Service Association Medicare	$70.14
Rate for Payer: Hawaii Western Management Group Commercial	$158.65
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Humana Medicare	$70.14
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: Kaiser Permanente Medicaid	$85.17
Rate for Payer: Kaiser Permanente Medicare	$70.14
Rate for Payer: MDX Hawaii PPO	$161.99
Rate for Payer: Ohana Health Plan Medicaid	$70.14
Rate for Payer: Ohana Health Plan Medicare	$70.14
Rate for Payer: UnitedHealthcare Medicaid	$11.85
Rate for Payer: UnitedHealthcare Medicare	$70.14
Rate for Payer: University Health Alliance Commercial	$121.73

E-STIM UNATTENDED Physical

Facility

$167.00

Service Code	HCPCS 97014 GP
Hospital Charge Code	426970140
Hospital Revenue Code	421
Min. Negotiated Rate	$141.95
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$108.55
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: MDX Hawaii PPO	$161.99

estradiol 0.0375 mg weekly ER patch [KMC]

Facility

$88.40

Service Code	NDC 47781020504
Hospital Revenue Code	250
Min. Negotiated Rate	$75.14
Max. Negotiated Rate	$85.75
Rate for Payer: Cash Price	$57.46
Rate for Payer: Health Management Network Commercial	$75.14
Rate for Payer: Kaiser Permanente Commercial	$79.56
Rate for Payer: MDX Hawaii PPO	$85.75

estradiol 0.0375 mg weekly ER patch [KMC]

Facility

$88.40

Service Code	NDC 47781020504
Hospital Revenue Code	250
Min. Negotiated Rate	$37.13
Max. Negotiated Rate	$85.75
Rate for Payer: AlohaCare Medicaid	$44.20
Rate for Payer: AlohaCare Medicare	$37.13
Rate for Payer: Cash Price	$57.46
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$81.33
Rate for Payer: Devoted Health Medicare	$37.13
Rate for Payer: Hawaii Medical Service Association Medicare	$37.13
Rate for Payer: Hawaii Western Management Group Commercial	$83.98
Rate for Payer: Health Management Network Commercial	$75.14
Rate for Payer: Humana Medicare	$37.13
Rate for Payer: Kaiser Permanente Commercial	$79.56
Rate for Payer: Kaiser Permanente Medicaid	$45.08
Rate for Payer: Kaiser Permanente Medicare	$37.13
Rate for Payer: MDX Hawaii PPO	$85.75
Rate for Payer: Ohana Health Plan Medicaid	$37.13
Rate for Payer: Ohana Health Plan Medicare	$37.13
Rate for Payer: UnitedHealthcare Medicaid	$53.04
Rate for Payer: UnitedHealthcare Medicare	$37.13
Rate for Payer: University Health Alliance Commercial	$64.43

estradiol 0.05 mg/24 hours weekly ER patch

Facility

$92.83

Service Code	NDC 00378335099
Hospital Revenue Code	250
Min. Negotiated Rate	$78.91
Max. Negotiated Rate	$90.05
Rate for Payer: Cash Price	$60.34
Rate for Payer: Health Management Network Commercial	$78.91
Rate for Payer: Kaiser Permanente Commercial	$83.55
Rate for Payer: MDX Hawaii PPO	$90.05

estradiol 0.05 mg/24 hours weekly ER patch

Facility

$92.83

Service Code	NDC 00378335099
Hospital Revenue Code	250
Min. Negotiated Rate	$38.99
Max. Negotiated Rate	$90.05
Rate for Payer: AlohaCare Medicaid	$46.41
Rate for Payer: AlohaCare Medicare	$38.99
Rate for Payer: Cash Price	$60.34
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$85.40
Rate for Payer: Devoted Health Medicare	$38.99
Rate for Payer: Hawaii Medical Service Association Medicare	$38.99
Rate for Payer: Hawaii Western Management Group Commercial	$88.19
Rate for Payer: Health Management Network Commercial	$78.91
Rate for Payer: Humana Medicare	$38.99
Rate for Payer: Kaiser Permanente Commercial	$83.55
Rate for Payer: Kaiser Permanente Medicaid	$47.34
Rate for Payer: Kaiser Permanente Medicare	$38.99
Rate for Payer: MDX Hawaii PPO	$90.05
Rate for Payer: Ohana Health Plan Medicaid	$38.99
Rate for Payer: Ohana Health Plan Medicare	$38.99
Rate for Payer: UnitedHealthcare Medicaid	$55.70
Rate for Payer: UnitedHealthcare Medicare	$38.99
Rate for Payer: University Health Alliance Commercial	$67.66

estradiol 0.1mg/24hr patch [KMC]

Facility

$97.84

Service Code	NDC 68968341008
Hospital Revenue Code	250
Min. Negotiated Rate	$41.09
Max. Negotiated Rate	$94.90
Rate for Payer: AlohaCare Medicaid	$48.92
Rate for Payer: AlohaCare Medicare	$41.09
Rate for Payer: Cash Price	$63.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$90.01
Rate for Payer: Devoted Health Medicare	$41.09
Rate for Payer: Hawaii Medical Service Association Medicare	$41.09
Rate for Payer: Hawaii Western Management Group Commercial	$92.95
Rate for Payer: Health Management Network Commercial	$83.16
Rate for Payer: Humana Medicare	$41.09
Rate for Payer: Kaiser Permanente Commercial	$88.06
Rate for Payer: Kaiser Permanente Medicaid	$49.90
Rate for Payer: Kaiser Permanente Medicare	$41.09
Rate for Payer: MDX Hawaii PPO	$94.90
Rate for Payer: Ohana Health Plan Medicaid	$41.09
Rate for Payer: Ohana Health Plan Medicare	$41.09
Rate for Payer: UnitedHealthcare Medicaid	$58.70
Rate for Payer: UnitedHealthcare Medicare	$41.09
Rate for Payer: University Health Alliance Commercial	$71.32

estradiol 0.1mg/24hr patch [KMC]

Facility

$97.84

Service Code	NDC 68968341008
Hospital Revenue Code	250
Min. Negotiated Rate	$83.16
Max. Negotiated Rate	$94.90
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$83.16
Rate for Payer: Kaiser Permanente Commercial	$88.06
Rate for Payer: MDX Hawaii PPO	$94.90

estradiol 0.1 mg/gm vaginal Cream [KMC]

Facility

$24.85

Service Code	NDC 00430375414
Hospital Revenue Code	250
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$24.10
Rate for Payer: AlohaCare Medicaid	$12.43
Rate for Payer: AlohaCare Medicare	$10.44
Rate for Payer: Cash Price	$16.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.86
Rate for Payer: Devoted Health Medicare	$10.44
Rate for Payer: Hawaii Medical Service Association Medicare	$10.44
Rate for Payer: Hawaii Western Management Group Commercial	$23.61
Rate for Payer: Health Management Network Commercial	$21.12
Rate for Payer: Humana Medicare	$10.44
Rate for Payer: Kaiser Permanente Commercial	$22.36
Rate for Payer: Kaiser Permanente Medicaid	$12.67
Rate for Payer: Kaiser Permanente Medicare	$10.44
Rate for Payer: MDX Hawaii PPO	$24.10
Rate for Payer: Ohana Health Plan Medicaid	$10.44
Rate for Payer: Ohana Health Plan Medicare	$10.44
Rate for Payer: UnitedHealthcare Medicaid	$14.91
Rate for Payer: UnitedHealthcare Medicare	$10.44
Rate for Payer: University Health Alliance Commercial	$18.11

estradiol 0.1 mg/gm vaginal Cream [KMC]

Facility

$24.85

Service Code	NDC 00430375414
Hospital Revenue Code	250
Min. Negotiated Rate	$21.12
Max. Negotiated Rate	$24.10
Rate for Payer: Cash Price	$16.15
Rate for Payer: Health Management Network Commercial	$21.12
Rate for Payer: Kaiser Permanente Commercial	$22.36
Rate for Payer: MDX Hawaii PPO	$24.10

estradiol 0.5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 72603027301
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

estradiol 0.5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 72603027301
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

estradiol 1 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00555088602
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

estradiol 1 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00555088602
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

Estradiol DLS

Facility

$252.00

Service Code	HCPCS 82670
Hospital Charge Code	422826705
Hospital Revenue Code	301
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$163.80
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: MDX Hawaii PPO	$244.44

Estradiol DLS

Facility

$252.00

Service Code	HCPCS 82670
Hospital Charge Code	422826705
Hospital Revenue Code	301
Min. Negotiated Rate	$27.94
Max. Negotiated Rate	$244.44
Rate for Payer: AlohaCare Medicaid	$126.00
Rate for Payer: AlohaCare Medicare	$105.84
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$231.84
Rate for Payer: Devoted Health Medicare	$105.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$38.62
Rate for Payer: Hawaii Medical Service Association Commercial	$34.92
Rate for Payer: Hawaii Medical Service Association Medicare	$105.84
Rate for Payer: Hawaii Western Management Group Commercial	$27.94
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Humana Medicare	$105.84
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$128.52
Rate for Payer: Kaiser Permanente Medicare	$105.84
Rate for Payer: MDX Hawaii PPO	$244.44
Rate for Payer: Ohana Health Plan Medicaid	$105.84
Rate for Payer: Ohana Health Plan Medicare	$105.84
Rate for Payer: UnitedHealthcare Medicaid	$38.62
Rate for Payer: UnitedHealthcare Medicare	$105.84
Rate for Payer: University Health Alliance Commercial	$72.22

Estriol, Unconjugated DLS

Facility

$202.00

Service Code	HCPCS 82677
Hospital Charge Code	422826775
Hospital Revenue Code	301
Min. Negotiated Rate	$24.18
Max. Negotiated Rate	$195.94
Rate for Payer: AlohaCare Medicaid	$101.00
Rate for Payer: AlohaCare Medicare	$84.84
Rate for Payer: Cash Price	$131.30
Rate for Payer: Cash Price	$131.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$185.84
Rate for Payer: Devoted Health Medicare	$84.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$33.43
Rate for Payer: Hawaii Medical Service Association Commercial	$30.23
Rate for Payer: Hawaii Medical Service Association Medicare	$84.84
Rate for Payer: Hawaii Western Management Group Commercial	$24.18
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Humana Medicare	$84.84
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: Kaiser Permanente Medicaid	$103.02
Rate for Payer: Kaiser Permanente Medicare	$84.84
Rate for Payer: MDX Hawaii PPO	$195.94
Rate for Payer: Ohana Health Plan Medicaid	$84.84
Rate for Payer: Ohana Health Plan Medicare	$84.84
Rate for Payer: UnitedHealthcare Medicaid	$33.43
Rate for Payer: UnitedHealthcare Medicare	$84.84
Rate for Payer: University Health Alliance Commercial	$62.51

Know your out-of-pocket cost for care.

All Charges