Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

Estrogen, Total DLS

Facility

$202.00

Service Code	HCPCS 82672
Hospital Charge Code	422826725
Hospital Revenue Code	301
Min. Negotiated Rate	$21.70
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	$29.97
Rate for Payer: Hawaii Medical Service Association Commercial	$27.12
Rate for Payer: Hawaii Medical Service Association Medicare	$84.84
Rate for Payer: Hawaii Western Management Group Commercial	$21.70
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	$29.97
Rate for Payer: UnitedHealthcare Medicare	$84.84
Rate for Payer: University Health Alliance Commercial	$56.05

Estrogen, Total DLS

Facility

$202.00

Service Code	HCPCS 82672
Hospital Charge Code	422826725
Hospital Revenue Code	301
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$131.30
Rate for Payer: Health Management Network Commercial	$171.70
Rate for Payer: Kaiser Permanente Commercial	$181.80
Rate for Payer: MDX Hawaii PPO	$195.94

eszopiclone 2 mg Tab[KMC]

Facility

$46.65

Service Code	NDC 00378527101
Hospital Revenue Code	250
Min. Negotiated Rate	$19.59
Max. Negotiated Rate	$45.25
Rate for Payer: AlohaCare Medicaid	$23.32
Rate for Payer: AlohaCare Medicare	$19.59
Rate for Payer: Cash Price	$30.32
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$42.92
Rate for Payer: Devoted Health Medicare	$19.59
Rate for Payer: Hawaii Medical Service Association Medicare	$19.59
Rate for Payer: Hawaii Western Management Group Commercial	$44.32
Rate for Payer: Health Management Network Commercial	$39.65
Rate for Payer: Humana Medicare	$19.59
Rate for Payer: Kaiser Permanente Commercial	$41.98
Rate for Payer: Kaiser Permanente Medicaid	$23.79
Rate for Payer: Kaiser Permanente Medicare	$19.59
Rate for Payer: MDX Hawaii PPO	$45.25
Rate for Payer: Ohana Health Plan Medicaid	$19.59
Rate for Payer: Ohana Health Plan Medicare	$19.59
Rate for Payer: UnitedHealthcare Medicaid	$27.99
Rate for Payer: UnitedHealthcare Medicare	$19.59
Rate for Payer: University Health Alliance Commercial	$34.00

eszopiclone 2 mg Tab[KMC]

Facility

$46.65

Service Code	NDC 00378527101
Hospital Revenue Code	250
Min. Negotiated Rate	$39.65
Max. Negotiated Rate	$45.25
Rate for Payer: Cash Price	$30.32
Rate for Payer: Health Management Network Commercial	$39.65
Rate for Payer: Kaiser Permanente Commercial	$41.98
Rate for Payer: MDX Hawaii PPO	$45.25

ethambutol 100 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

ethambutol 100 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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

ethambutol 400 mg Tab [KMC]

Facility

$6.24

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$6.05
Rate for Payer: AlohaCare Medicaid	$3.12
Rate for Payer: AlohaCare Medicare	$2.62
Rate for Payer: Cash Price	$4.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.74
Rate for Payer: Devoted Health Medicare	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.62
Rate for Payer: Hawaii Western Management Group Commercial	$5.93
Rate for Payer: Health Management Network Commercial	$5.30
Rate for Payer: Humana Medicare	$2.62
Rate for Payer: Kaiser Permanente Commercial	$5.62
Rate for Payer: Kaiser Permanente Medicaid	$3.18
Rate for Payer: Kaiser Permanente Medicare	$2.62
Rate for Payer: MDX Hawaii PPO	$6.05
Rate for Payer: Ohana Health Plan Medicaid	$2.62
Rate for Payer: Ohana Health Plan Medicare	$2.62
Rate for Payer: UnitedHealthcare Medicare	$2.62
Rate for Payer: University Health Alliance Commercial	$4.55

ethambutol 400 mg Tab [KMC]

Facility

$6.24

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$5.30
Max. Negotiated Rate	$6.05
Rate for Payer: Cash Price	$4.06
Rate for Payer: Health Management Network Commercial	$5.30
Rate for Payer: Kaiser Permanente Commercial	$5.62
Rate for Payer: MDX Hawaii PPO	$6.05

Ethanol DLS

Facility

$60.00

Service Code	HCPCS 80320
Hospital Charge Code	422803205
Hospital Revenue Code	301
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$39.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: MDX Hawaii PPO	$58.20

Ethanol DLS

Facility

$60.00

Service Code	HCPCS 80320
Hospital Charge Code	422803205
Hospital Revenue Code	301
Min. Negotiated Rate	$14.93
Max. Negotiated Rate	$58.20
Rate for Payer: AlohaCare Medicaid	$30.00
Rate for Payer: AlohaCare Medicare	$25.20
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$55.20
Rate for Payer: Devoted Health Medicare	$25.20
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.93
Rate for Payer: Hawaii Medical Service Association Medicare	$25.20
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Humana Medicare	$25.20
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicare	$25.20
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: Ohana Health Plan Medicaid	$25.20
Rate for Payer: Ohana Health Plan Medicare	$25.20
Rate for Payer: UnitedHealthcare Medicare	$25.20
Rate for Payer: University Health Alliance Commercial	$43.73

Ethanol Level

Facility

$208.00

Service Code	HCPCS 80320
Hospital Charge Code	422803200
Hospital Revenue Code	301
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$135.20
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

Ethanol Level

Facility

$208.00

Service Code	HCPCS 80320
Hospital Charge Code	422803200
Hospital Revenue Code	301
Min. Negotiated Rate	$14.93
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$87.36
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$191.36
Rate for Payer: Devoted Health Medicare	$87.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.93
Rate for Payer: Hawaii Medical Service Association Medicare	$87.36
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$87.36
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$87.36
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$87.36
Rate for Payer: Ohana Health Plan Medicare	$87.36
Rate for Payer: UnitedHealthcare Medicare	$87.36
Rate for Payer: University Health Alliance Commercial	$151.61

ethyl chloride 100% topical Spray [KMC]

Facility

$1.37

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$1.33
Rate for Payer: AlohaCare Medicaid	$0.69
Rate for Payer: AlohaCare Medicare	$0.58
Rate for Payer: Cash Price	$0.89
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.26
Rate for Payer: Devoted Health Medicare	$0.58
Rate for Payer: Hawaii Medical Service Association Medicare	$0.58
Rate for Payer: Hawaii Western Management Group Commercial	$1.30
Rate for Payer: Health Management Network Commercial	$1.16
Rate for Payer: Humana Medicare	$0.58
Rate for Payer: Kaiser Permanente Commercial	$1.23
Rate for Payer: Kaiser Permanente Medicaid	$0.70
Rate for Payer: Kaiser Permanente Medicare	$0.58
Rate for Payer: MDX Hawaii PPO	$1.33
Rate for Payer: Ohana Health Plan Medicaid	$0.58
Rate for Payer: Ohana Health Plan Medicare	$0.58
Rate for Payer: UnitedHealthcare Medicare	$0.58
Rate for Payer: University Health Alliance Commercial	$1.00

ethyl chloride 100% topical Spray [KMC]

Facility

$1.37

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Management Network Commercial	$1.16
Rate for Payer: Kaiser Permanente Commercial	$1.23
Rate for Payer: MDX Hawaii PPO	$1.33

etomidate 20 mg/10 mL Soln [KMC]

Facility

$2.47

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$2.40
Rate for Payer: AlohaCare Medicaid	$1.24
Rate for Payer: AlohaCare Medicare	$1.04
Rate for Payer: Cash Price	$1.61
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.27
Rate for Payer: Devoted Health Medicare	$1.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.04
Rate for Payer: Hawaii Western Management Group Commercial	$2.35
Rate for Payer: Health Management Network Commercial	$2.10
Rate for Payer: Humana Medicare	$1.04
Rate for Payer: Kaiser Permanente Commercial	$2.22
Rate for Payer: Kaiser Permanente Medicaid	$1.26
Rate for Payer: Kaiser Permanente Medicare	$1.04
Rate for Payer: MDX Hawaii PPO	$2.40
Rate for Payer: Ohana Health Plan Medicaid	$1.04
Rate for Payer: Ohana Health Plan Medicare	$1.04
Rate for Payer: UnitedHealthcare Medicaid	$1.48
Rate for Payer: UnitedHealthcare Medicare	$1.04
Rate for Payer: University Health Alliance Commercial	$1.80

etomidate 20 mg/10 mL Soln [KMC]

Facility

$2.47

Service Code	HCPCS J3490
Hospital Revenue Code	636
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$2.40
Rate for Payer: Cash Price	$1.61
Rate for Payer: Health Management Network Commercial	$2.10
Rate for Payer: Kaiser Permanente Commercial	$2.22
Rate for Payer: MDX Hawaii PPO	$2.40

etravirine 200 mg Tab [KMC]

Facility

$102.98

Service Code	NDC 69315028606
Hospital Revenue Code	250
Min. Negotiated Rate	$43.25
Max. Negotiated Rate	$99.89
Rate for Payer: AlohaCare Medicaid	$51.49
Rate for Payer: AlohaCare Medicare	$43.25
Rate for Payer: Cash Price	$66.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$94.74
Rate for Payer: Devoted Health Medicare	$43.25
Rate for Payer: Hawaii Medical Service Association Medicare	$43.25
Rate for Payer: Hawaii Western Management Group Commercial	$97.83
Rate for Payer: Health Management Network Commercial	$87.53
Rate for Payer: Humana Medicare	$43.25
Rate for Payer: Kaiser Permanente Commercial	$92.68
Rate for Payer: Kaiser Permanente Medicaid	$52.52
Rate for Payer: Kaiser Permanente Medicare	$43.25
Rate for Payer: MDX Hawaii PPO	$99.89
Rate for Payer: Ohana Health Plan Medicaid	$43.25
Rate for Payer: Ohana Health Plan Medicare	$43.25
Rate for Payer: UnitedHealthcare Medicaid	$61.79
Rate for Payer: UnitedHealthcare Medicare	$43.25
Rate for Payer: University Health Alliance Commercial	$75.06

etravirine 200 mg Tab [KMC]

Facility

$102.98

Service Code	NDC 69315028606
Hospital Revenue Code	250
Min. Negotiated Rate	$87.53
Max. Negotiated Rate	$99.89
Rate for Payer: Cash Price	$66.94
Rate for Payer: Health Management Network Commercial	$87.53
Rate for Payer: Kaiser Permanente Commercial	$92.68
Rate for Payer: MDX Hawaii PPO	$99.89

Eucerin topical cream [KMC]

Facility

$0.19

Service Code	NDC 72140000220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
Rate for Payer: AlohaCare Medicaid	$0.10
Rate for Payer: AlohaCare Medicare	$0.08
Rate for Payer: Cash Price	$0.12
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.17
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Hawaii Medical Service Association Medicare	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$0.18
Rate for Payer: Health Management Network Commercial	$0.16
Rate for Payer: Humana Medicare	$0.08
Rate for Payer: Kaiser Permanente Commercial	$0.17
Rate for Payer: Kaiser Permanente Medicaid	$0.10
Rate for Payer: Kaiser Permanente Medicare	$0.08
Rate for Payer: MDX Hawaii PPO	$0.18
Rate for Payer: Ohana Health Plan Medicaid	$0.08
Rate for Payer: Ohana Health Plan Medicare	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.11
Rate for Payer: UnitedHealthcare Medicare	$0.08
Rate for Payer: University Health Alliance Commercial	$0.14

Eucerin topical cream [KMC]

Facility

$0.19

Service Code	NDC 72140000220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Management Network Commercial	$0.16
Rate for Payer: Kaiser Permanente Commercial	$0.17
Rate for Payer: MDX Hawaii PPO	$0.18

EVAC SUBUNGUAL HEMATOMA ED Charge

Facility

$311.00

Service Code	HCPCS 11740
Hospital Charge Code	440117400
Hospital Revenue Code	450
Min. Negotiated Rate	$264.35
Max. Negotiated Rate	$301.67
Rate for Payer: Cash Price	$202.15
Rate for Payer: Health Management Network Commercial	$264.35
Rate for Payer: Kaiser Permanente Commercial	$279.90
Rate for Payer: MDX Hawaii PPO	$301.67

EVAC SUBUNGUAL HEMATOMA ED Charge

Facility

$311.00

Service Code	HCPCS 11740
Hospital Charge Code	440117400
Hospital Revenue Code	450
Min. Negotiated Rate	$130.62
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$155.50
Rate for Payer: AlohaCare Medicare	$130.62
Rate for Payer: Cash Price	$202.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$286.12
Rate for Payer: Devoted Health Medicare	$130.62
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	$130.62
Rate for Payer: Hawaii Western Management Group Commercial	$295.45
Rate for Payer: Health Management Network Commercial	$264.35
Rate for Payer: Humana Medicare	$130.62
Rate for Payer: Kaiser Permanente Commercial	$279.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$130.62
Rate for Payer: MDX Hawaii PPO	$301.67
Rate for Payer: Ohana Health Plan Medicaid	$130.62
Rate for Payer: Ohana Health Plan Medicare	$130.62
Rate for Payer: UnitedHealthcare Medicare	$130.62
Rate for Payer: University Health Alliance Commercial	$226.69

EVACUATION SUBUNGUAL HEMATOMA

Professional

Both

$224.00

Service Code	HCPCS 11740
Hospital Revenue Code	361
Min. Negotiated Rate	$31.98
Max. Negotiated Rate	$190.40
Rate for Payer: AlohaCare Medicaid	$34.68
Rate for Payer: AlohaCare Medicare	$33.49
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cash Price	$145.60
Rate for Payer: Devoted Health Medicare	$33.49
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$34.68
Rate for Payer: Hawaii Medical Service Association Commercial	$51.06
Rate for Payer: Hawaii Medical Service Association Medicare	$33.49
Rate for Payer: Hawaii Western Management Group Commercial	$31.98
Rate for Payer: Health Management Network Commercial	$190.40
Rate for Payer: Kaiser Permanente Commercial	$40.19
Rate for Payer: Kaiser Permanente Medicaid	$40.19
Rate for Payer: Kaiser Permanente Medicare	$40.19
Rate for Payer: Ohana Health Plan Medicaid	$34.68
Rate for Payer: Ohana Health Plan Medicare	$33.49
Rate for Payer: UnitedHealthcare Medicaid	$34.68
Rate for Payer: UnitedHealthcare Medicare	$33.49
Rate for Payer: University Health Alliance Commercial	$38.23

EVAL OF ORTHOTIC/PROSTH USE, EA 15 MIN

Professional

Both

$194.00

Service Code	HCPCS 97762
Hospital Revenue Code	420
Min. Negotiated Rate	$55.06
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$126.10
Rate for Payer: Cash Price	$126.10
Rate for Payer: Hawaii Western Management Group Commercial	$55.06
Rate for Payer: Health Management Network Commercial	$164.90

Know your out-of-pocket cost for care.

All Charges