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All Charges

Charge

Type

Setting

Price

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]

Facility

IP

$101.00

Service Code	NDC 65219005229
Hospital Revenue Code	250
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]

Facility

IP

$101.00

Service Code	NDC 65219005209
Hospital Revenue Code	250
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$60.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]

Facility

IP

$42.00

Service Code	NDC 00409729501
Hospital Revenue Code	250
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$3.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Health Management Network Commercial	$11.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Commercial	$12.60
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: MDX Hawaii PPO	$13.58
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: MDX Hawaii PPO	$4.85

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]

Facility

IP

$202.00

Service Code	NDC 00517210201
Hospital Revenue Code	250
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$121.20
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

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]

Facility

IP

$189.00

Service Code	NDC 80830169101
Hospital Revenue Code	250
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$113.40
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: MDX Hawaii PPO	$183.33

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]

Facility

IP

$202.00

Service Code	NDC 00517210225
Hospital Revenue Code	250
Min. Negotiated Rate	$171.70
Max. Negotiated Rate	$195.94
Rate for Payer: Cash Price	$121.20
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

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

OP

$3.00

Service Code	NDC 00601000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

IP

$3.00

Service Code	NDC 00615000000
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

OP

$3.00

Service Code	NDC 00615000000
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]

Facility

IP

$3.00

Service Code	NDC 00601000000
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]

Facility

IP

$8.00

Service Code	NDC 00536127180
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]

Facility

OP

$8.00

Service Code	NDC 00536127180
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$6.08
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$6.72
Rate for Payer: Hawaii Medical Service Association Medicare	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$6.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$6.08
Rate for Payer: UnitedHealthcare Medicare	$6.08
Rate for Payer: University Health Alliance Commercial	$5.83

POVIDONE-IODINE 5 % EYE SOLUTION [19791]

Facility

IP

$75.00

Service Code	NDC 00065041130
Hospital Revenue Code	250
Min. Negotiated Rate	$63.75
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: MDX Hawaii PPO	$72.75

POVIDONE-IODINE 5 % EYE SOLUTION [19791]

Facility

OP

$75.00

Service Code	NDC 00065041130
Hospital Revenue Code	637
Min. Negotiated Rate	$37.50
Max. Negotiated Rate	$72.75
Rate for Payer: AlohaCare Medicaid	$37.50
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Devoted Health Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$71.25
Rate for Payer: Health Management Network Commercial	$63.75
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$67.50
Rate for Payer: Kaiser Permanente Medicaid	$38.25
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$72.75
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$54.67

POWER DRIVER ON-CONTROL

Facility

OP

$2,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$1,824.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$2,016.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,824.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,280.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$1,824.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$1,824.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$1,824.00
Rate for Payer: Ohana Health Plan Medicare	$1,824.00
Rate for Payer: UnitedHealthcare Medicare	$1,824.00
Rate for Payer: University Health Alliance Commercial	$1,749.36

POWER DRIVER ON-CONTROL

Facility

IP

$2,400.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00

POWERPORT SLIM 6FR 1716000

Facility

OP

$889.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$444.50
Max. Negotiated Rate	$862.33
Rate for Payer: AlohaCare Medicaid	$444.50
Rate for Payer: AlohaCare Medicare	$675.64
Rate for Payer: Cash Price	$533.40
Rate for Payer: Devoted Health Medicare	$746.76
Rate for Payer: Hawaii Medical Service Association Medicare	$675.64
Rate for Payer: Hawaii Western Management Group Commercial	$622.30
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: Humana Medicare	$675.64
Rate for Payer: Kaiser Permanente Commercial	$800.10
Rate for Payer: Kaiser Permanente Medicaid	$453.39
Rate for Payer: Kaiser Permanente Medicare	$675.64
Rate for Payer: MDX Hawaii PPO	$862.33
Rate for Payer: Ohana Health Plan Medicaid	$675.64
Rate for Payer: Ohana Health Plan Medicare	$675.64
Rate for Payer: UnitedHealthcare Medicare	$675.64
Rate for Payer: University Health Alliance Commercial	$497.84

POWERPORT SLIM 6FR 1716000

Facility

IP

$889.00

Service Code	HCPCS C1788
Hospital Revenue Code	278
Min. Negotiated Rate	$497.84
Max. Negotiated Rate	$862.33
Rate for Payer: Cash Price	$533.40
Rate for Payer: Hawaii Western Management Group Commercial	$622.30
Rate for Payer: Health Management Network Commercial	$755.65
Rate for Payer: Kaiser Permanente Commercial	$800.10
Rate for Payer: MDX Hawaii PPO	$862.33
Rate for Payer: University Health Alliance Commercial	$497.84

POWER RASP 4.0 AR-8400PR

Facility

OP

$544.00

Hospital Revenue Code	272
Min. Negotiated Rate	$272.00
Max. Negotiated Rate	$527.68
Rate for Payer: AlohaCare Medicaid	$272.00
Rate for Payer: AlohaCare Medicare	$413.44
Rate for Payer: Cash Price	$326.40
Rate for Payer: Devoted Health Medicare	$456.96
Rate for Payer: Hawaii Medical Service Association Medicare	$413.44
Rate for Payer: Hawaii Western Management Group Commercial	$516.80
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Humana Medicare	$413.44
Rate for Payer: Kaiser Permanente Commercial	$489.60
Rate for Payer: Kaiser Permanente Medicaid	$277.44
Rate for Payer: Kaiser Permanente Medicare	$413.44
Rate for Payer: MDX Hawaii PPO	$527.68
Rate for Payer: Ohana Health Plan Medicaid	$413.44
Rate for Payer: Ohana Health Plan Medicare	$413.44
Rate for Payer: UnitedHealthcare Medicare	$413.44
Rate for Payer: University Health Alliance Commercial	$396.52

POWER RASP 4.0 AR-8400PR

Facility

IP

$544.00

Hospital Revenue Code	272
Min. Negotiated Rate	$462.40
Max. Negotiated Rate	$527.68
Rate for Payer: Cash Price	$326.40
Rate for Payer: Health Management Network Commercial	$462.40
Rate for Payer: Kaiser Permanente Commercial	$489.60
Rate for Payer: MDX Hawaii PPO	$527.68

PR 1ST CARE PR DAY NML NB XCPT HOSP/BIRTHING CENTER

Professional

Both

$174.37

Service Code	HCPCS 99461
Min. Negotiated Rate	$47.09
Max. Negotiated Rate	$148.21
Rate for Payer: AlohaCare Medicaid	$61.22
Rate for Payer: AlohaCare Medicare	$53.31
Rate for Payer: Cash Price	$104.62
Rate for Payer: Cash Price	$104.62
Rate for Payer: Devoted Health Medicare	$58.64
Rate for Payer: Hawaii Medical Service Association ABD	$61.22
Rate for Payer: Hawaii Medical Service Association Medicare	$53.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.22
Rate for Payer: Hawaii Western Management Group Commercial	$47.09
Rate for Payer: Health Management Network Commercial	$148.21
Rate for Payer: Kaiser Permanente Commercial	$63.97
Rate for Payer: Kaiser Permanente Medicaid	$63.97
Rate for Payer: Kaiser Permanente Medicare	$63.97
Rate for Payer: Ohana Health Plan Medicaid	$61.22
Rate for Payer: Ohana Health Plan Medicare	$53.31
Rate for Payer: UnitedHealthcare Medicaid	$61.22
Rate for Payer: UnitedHealthcare Medicare	$53.31
Rate for Payer: University Health Alliance Commercial	$75.09

PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB

Professional

Both

$158.00

Service Code	HCPCS 99460
Min. Negotiated Rate	$77.34
Max. Negotiated Rate	$134.30
Rate for Payer: AlohaCare Medicaid	$93.11
Rate for Payer: AlohaCare Medicare	$80.88
Rate for Payer: Cash Price	$94.80
Rate for Payer: Cash Price	$94.80
Rate for Payer: Devoted Health Medicare	$88.97
Rate for Payer: Hawaii Medical Service Association Medicare	$80.88
Rate for Payer: Hawaii Western Management Group Commercial	$77.34
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$97.06
Rate for Payer: Kaiser Permanente Medicaid	$97.06
Rate for Payer: Kaiser Permanente Medicare	$97.06
Rate for Payer: Ohana Health Plan Medicaid	$93.11
Rate for Payer: Ohana Health Plan Medicare	$80.88
Rate for Payer: UnitedHealthcare Medicaid	$93.11
Rate for Payer: UnitedHealthcare Medicare	$80.88

PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT

Professional

Both

$185.00

Service Code	HCPCS 99463
Min. Negotiated Rate	$95.68
Max. Negotiated Rate	$157.25
Rate for Payer: AlohaCare Medicaid	$109.27
Rate for Payer: AlohaCare Medicare	$95.68
Rate for Payer: Cash Price	$111.00
Rate for Payer: Cash Price	$111.00
Rate for Payer: Devoted Health Medicare	$105.25
Rate for Payer: Hawaii Medical Service Association Medicare	$95.68
Rate for Payer: Hawaii Western Management Group Commercial	$97.81
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$114.82
Rate for Payer: Kaiser Permanente Medicaid	$114.82
Rate for Payer: Kaiser Permanente Medicare	$114.82
Rate for Payer: Ohana Health Plan Medicaid	$109.27
Rate for Payer: Ohana Health Plan Medicare	$95.68
Rate for Payer: UnitedHealthcare Medicaid	$109.27
Rate for Payer: UnitedHealthcare Medicare	$95.68

PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES

Professional

Both

$297.00

Service Code	HCPCS 99223
Min. Negotiated Rate	$149.55
Max. Negotiated Rate	$252.45
Rate for Payer: AlohaCare Medicaid	$174.14
Rate for Payer: AlohaCare Medicare	$156.50
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cash Price	$178.20
Rate for Payer: Devoted Health Medicare	$172.15
Rate for Payer: Hawaii Medical Service Association Medicare	$156.50
Rate for Payer: Hawaii Western Management Group Commercial	$149.55
Rate for Payer: Health Management Network Commercial	$252.45
Rate for Payer: Kaiser Permanente Commercial	$187.80
Rate for Payer: Kaiser Permanente Medicaid	$187.80
Rate for Payer: Kaiser Permanente Medicare	$187.80
Rate for Payer: Ohana Health Plan Medicaid	$174.14
Rate for Payer: Ohana Health Plan Medicare	$156.50
Rate for Payer: UnitedHealthcare Medicaid	$174.14
Rate for Payer: UnitedHealthcare Medicare	$156.50

PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES

Professional

Both

$223.00

Service Code	HCPCS 99222
Min. Negotiated Rate	$113.39
Max. Negotiated Rate	$189.55
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$116.73
Rate for Payer: Cash Price	$133.80
Rate for Payer: Cash Price	$133.80
Rate for Payer: Devoted Health Medicare	$128.40
Rate for Payer: Hawaii Medical Service Association Medicare	$116.73
Rate for Payer: Hawaii Western Management Group Commercial	$113.39
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$140.08
Rate for Payer: Kaiser Permanente Medicaid	$140.08
Rate for Payer: Kaiser Permanente Medicare	$140.08
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$116.73
Rate for Payer: UnitedHealthcare Medicaid	$131.00
Rate for Payer: UnitedHealthcare Medicare	$116.73

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