Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Iontophoresis Charges

Facility

$129.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	432970330
Hospital Revenue Code	420
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

Iontophoresis Charges

Facility

$144.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	426970330
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicare	$60.48
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$132.48
Rate for Payer: Devoted Health Medicare	$60.48
Rate for Payer: Hawaii Medical Service Association Medicare	$60.48
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$60.48
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$60.48
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$60.48
Rate for Payer: Ohana Health Plan Medicare	$60.48
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$60.48
Rate for Payer: University Health Alliance Commercial	$104.96

Iontophoresis Charges

Facility

$129.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	432970330
Hospital Revenue Code	420
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$54.18
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.68
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Hawaii Medical Service Association Medicare	$54.18
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$54.18
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$54.18
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$54.18
Rate for Payer: Ohana Health Plan Medicare	$54.18
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$54.18
Rate for Payer: University Health Alliance Commercial	$94.03

Iontophoresis Charges

Facility

$144.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	426970330
Hospital Revenue Code	430
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: MDX Hawaii PPO	$139.68

IONTOPHORESIS EACH 15 MIN Occupational

Facility

$144.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	426970330
Hospital Revenue Code	430
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicare	$60.48
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$132.48
Rate for Payer: Devoted Health Medicare	$60.48
Rate for Payer: Hawaii Medical Service Association Medicare	$60.48
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$60.48
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$60.48
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$60.48
Rate for Payer: Ohana Health Plan Medicare	$60.48
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$60.48
Rate for Payer: University Health Alliance Commercial	$104.96

IONTOPHORESIS EACH 15 MIN Occupational

Facility

$144.00

Service Code	HCPCS 97033 GO
Hospital Charge Code	426970330
Hospital Revenue Code	430
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: MDX Hawaii PPO	$139.68

IONTOPHORESIS EACH 15 MIN Physical

Facility

$129.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	432970330
Hospital Revenue Code	420
Min. Negotiated Rate	$13.64
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$54.18
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.68
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Hawaii Medical Service Association Medicare	$54.18
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$54.18
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$54.18
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$54.18
Rate for Payer: Ohana Health Plan Medicare	$54.18
Rate for Payer: UnitedHealthcare Medicaid	$13.64
Rate for Payer: UnitedHealthcare Medicare	$54.18
Rate for Payer: University Health Alliance Commercial	$94.03

IONTOPHORESIS EACH 15 MIN Physical

Facility

$129.00

Service Code	HCPCS 97033 GP
Hospital Charge Code	432970330
Hospital Revenue Code	420
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

ipratropium 17 mcg inhaler [KMC]

Facility

$165.57

Service Code	NDC 00597008717
Hospital Revenue Code	250
Min. Negotiated Rate	$69.54
Max. Negotiated Rate	$160.60
Rate for Payer: AlohaCare Medicaid	$82.78
Rate for Payer: AlohaCare Medicare	$69.54
Rate for Payer: Cash Price	$107.62
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$152.32
Rate for Payer: Devoted Health Medicare	$69.54
Rate for Payer: Hawaii Medical Service Association Medicare	$69.54
Rate for Payer: Hawaii Western Management Group Commercial	$157.29
Rate for Payer: Health Management Network Commercial	$140.73
Rate for Payer: Humana Medicare	$69.54
Rate for Payer: Kaiser Permanente Commercial	$149.01
Rate for Payer: Kaiser Permanente Medicaid	$84.44
Rate for Payer: Kaiser Permanente Medicare	$69.54
Rate for Payer: MDX Hawaii PPO	$160.60
Rate for Payer: Ohana Health Plan Medicaid	$69.54
Rate for Payer: Ohana Health Plan Medicare	$69.54
Rate for Payer: UnitedHealthcare Medicaid	$99.34
Rate for Payer: UnitedHealthcare Medicare	$69.54
Rate for Payer: University Health Alliance Commercial	$120.68

ipratropium 17 mcg inhaler [KMC]

Facility

$165.57

Service Code	NDC 00597008717
Hospital Revenue Code	250
Min. Negotiated Rate	$140.73
Max. Negotiated Rate	$160.60
Rate for Payer: Cash Price	$107.62
Rate for Payer: Health Management Network Commercial	$140.73
Rate for Payer: Kaiser Permanente Commercial	$149.01
Rate for Payer: MDX Hawaii PPO	$160.60

ipratropium 500 mcg/2.5 mL Neb Soln [KMC]

Facility

$0.58

Service Code	HCPCS J7644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.56
Rate for Payer: AlohaCare Medicaid	$0.29
Rate for Payer: AlohaCare Medicare	$0.24
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cash Price	$0.38
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.53
Rate for Payer: Devoted Health Medicare	$0.24
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.39
Rate for Payer: Hawaii Medical Service Association Medicare	$0.24
Rate for Payer: Hawaii Western Management Group Commercial	$0.55
Rate for Payer: Health Management Network Commercial	$0.49
Rate for Payer: Humana Medicare	$0.24
Rate for Payer: Kaiser Permanente Commercial	$0.52
Rate for Payer: Kaiser Permanente Medicaid	$0.30
Rate for Payer: Kaiser Permanente Medicare	$0.24
Rate for Payer: MDX Hawaii PPO	$0.56
Rate for Payer: Ohana Health Plan Medicaid	$0.24
Rate for Payer: Ohana Health Plan Medicare	$0.24
Rate for Payer: UnitedHealthcare Medicaid	$0.35
Rate for Payer: UnitedHealthcare Medicare	$0.24
Rate for Payer: University Health Alliance Commercial	$0.42

ipratropium 500 mcg/2.5 mL Neb Soln [KMC]

Facility

$0.58

Service Code	HCPCS J7644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.38
Rate for Payer: Health Management Network Commercial	$0.49
Rate for Payer: Kaiser Permanente Commercial	$0.52
Rate for Payer: MDX Hawaii PPO	$0.56

irbesartan 150 mg Tab

Facility

$12.28

Service Code	NDC 33342004810
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$11.91
Rate for Payer: AlohaCare Medicaid	$6.14
Rate for Payer: AlohaCare Medicare	$5.16
Rate for Payer: Cash Price	$7.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.30
Rate for Payer: Devoted Health Medicare	$5.16
Rate for Payer: Hawaii Medical Service Association Medicare	$5.16
Rate for Payer: Hawaii Western Management Group Commercial	$11.67
Rate for Payer: Health Management Network Commercial	$10.44
Rate for Payer: Humana Medicare	$5.16
Rate for Payer: Kaiser Permanente Commercial	$11.05
Rate for Payer: Kaiser Permanente Medicaid	$6.26
Rate for Payer: Kaiser Permanente Medicare	$5.16
Rate for Payer: MDX Hawaii PPO	$11.91
Rate for Payer: Ohana Health Plan Medicaid	$5.16
Rate for Payer: Ohana Health Plan Medicare	$5.16
Rate for Payer: UnitedHealthcare Medicaid	$7.37
Rate for Payer: UnitedHealthcare Medicare	$5.16
Rate for Payer: University Health Alliance Commercial	$8.95

irbesartan 150 mg Tab

Facility

$12.28

Service Code	NDC 33342004810
Hospital Revenue Code	250
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$11.91
Rate for Payer: Cash Price	$7.98
Rate for Payer: Health Management Network Commercial	$10.44
Rate for Payer: Kaiser Permanente Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$11.91

irbesartan 300 mg Tab [KMC]

Facility

$36.27

Service Code	NDC 00024585230
Hospital Revenue Code	250
Min. Negotiated Rate	$30.83
Max. Negotiated Rate	$35.18
Rate for Payer: Cash Price	$23.58
Rate for Payer: Health Management Network Commercial	$30.83
Rate for Payer: Kaiser Permanente Commercial	$32.64
Rate for Payer: MDX Hawaii PPO	$35.18

irbesartan 300 mg Tab [KMC]

Facility

$36.27

Service Code	NDC 00024585230
Hospital Revenue Code	250
Min. Negotiated Rate	$15.23
Max. Negotiated Rate	$35.18
Rate for Payer: AlohaCare Medicaid	$18.14
Rate for Payer: AlohaCare Medicare	$15.23
Rate for Payer: Cash Price	$23.58
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.37
Rate for Payer: Devoted Health Medicare	$15.23
Rate for Payer: Hawaii Medical Service Association Medicare	$15.23
Rate for Payer: Hawaii Western Management Group Commercial	$34.46
Rate for Payer: Health Management Network Commercial	$30.83
Rate for Payer: Humana Medicare	$15.23
Rate for Payer: Kaiser Permanente Commercial	$32.64
Rate for Payer: Kaiser Permanente Medicaid	$18.50
Rate for Payer: Kaiser Permanente Medicare	$15.23
Rate for Payer: MDX Hawaii PPO	$35.18
Rate for Payer: Ohana Health Plan Medicaid	$15.23
Rate for Payer: Ohana Health Plan Medicare	$15.23
Rate for Payer: UnitedHealthcare Medicaid	$21.76
Rate for Payer: UnitedHealthcare Medicare	$15.23
Rate for Payer: University Health Alliance Commercial	$26.44

iron dextran 100 mg / 2 mL Soln [KMC]

Facility

$77.30

Service Code	HCPCS J1750
Hospital Revenue Code	636
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$74.98
Rate for Payer: Cash Price	$50.24
Rate for Payer: Health Management Network Commercial	$65.70
Rate for Payer: Kaiser Permanente Commercial	$69.57
Rate for Payer: MDX Hawaii PPO	$74.98

iron dextran 100 mg / 2 mL Soln [KMC]

Facility

$77.30

Service Code	HCPCS J1750
Hospital Revenue Code	636
Min. Negotiated Rate	$18.03
Max. Negotiated Rate	$74.98
Rate for Payer: AlohaCare Medicaid	$38.65
Rate for Payer: AlohaCare Medicare	$32.47
Rate for Payer: Cash Price	$50.24
Rate for Payer: Cash Price	$50.24
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$71.12
Rate for Payer: Devoted Health Medicare	$32.47
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.03
Rate for Payer: Hawaii Medical Service Association Commercial	$22.64
Rate for Payer: Hawaii Medical Service Association Medicare	$32.47
Rate for Payer: Hawaii Western Management Group Commercial	$73.44
Rate for Payer: Health Management Network Commercial	$65.70
Rate for Payer: Humana Medicare	$32.47
Rate for Payer: Kaiser Permanente Commercial	$69.57
Rate for Payer: Kaiser Permanente Medicaid	$39.42
Rate for Payer: Kaiser Permanente Medicare	$32.47
Rate for Payer: MDX Hawaii PPO	$74.98
Rate for Payer: Ohana Health Plan Medicaid	$32.47
Rate for Payer: Ohana Health Plan Medicare	$32.47
Rate for Payer: UnitedHealthcare Medicaid	$46.38
Rate for Payer: UnitedHealthcare Medicare	$32.47
Rate for Payer: University Health Alliance Commercial	$56.34

Iron, IBC & % Saturation DLS

Facility

$110.00

Service Code	HCPCS 83550
Hospital Charge Code	422835505
Hospital Revenue Code	301
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$71.50
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: MDX Hawaii PPO	$106.70

Iron, IBC & % Saturation DLS

Facility

$110.00

Service Code	HCPCS 83550
Hospital Charge Code	422835505
Hospital Revenue Code	301
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$106.70
Rate for Payer: AlohaCare Medicaid	$55.00
Rate for Payer: AlohaCare Medicare	$46.20
Rate for Payer: Cash Price	$71.50
Rate for Payer: Cash Price	$71.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$101.20
Rate for Payer: Devoted Health Medicare	$46.20
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$12.08
Rate for Payer: Hawaii Medical Service Association Commercial	$10.93
Rate for Payer: Hawaii Medical Service Association Medicare	$46.20
Rate for Payer: Hawaii Western Management Group Commercial	$8.74
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Humana Medicare	$46.20
Rate for Payer: Kaiser Permanente Commercial	$99.00
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: Kaiser Permanente Medicare	$46.20
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: Ohana Health Plan Medicaid	$46.20
Rate for Payer: Ohana Health Plan Medicare	$46.20
Rate for Payer: UnitedHealthcare Medicaid	$12.08
Rate for Payer: UnitedHealthcare Medicare	$46.20
Rate for Payer: University Health Alliance Commercial	$22.59

iron sucrose 200 mg / 10 mL Soln [KMC]

Facility

$48.00

Service Code	HCPCS J1756
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$20.16
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$44.16
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Medicare	$20.16
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$20.16
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$20.16
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$20.16
Rate for Payer: Ohana Health Plan Medicare	$20.16
Rate for Payer: UnitedHealthcare Medicaid	$28.80
Rate for Payer: UnitedHealthcare Medicare	$20.16
Rate for Payer: University Health Alliance Commercial	$34.99

iron sucrose 200 mg / 10 mL Soln [KMC]

Facility

$48.00

Service Code	HCPCS J1756
Hospital Revenue Code	636
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$31.20
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

Iron, Total DLS

Facility

$36.00

Service Code	HCPCS 83540
Hospital Charge Code	422835405
Hospital Revenue Code	301
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$34.92
Rate for Payer: AlohaCare Medicaid	$18.00
Rate for Payer: AlohaCare Medicare	$15.12
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.12
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.95
Rate for Payer: Hawaii Medical Service Association Commercial	$8.09
Rate for Payer: Hawaii Medical Service Association Medicare	$15.12
Rate for Payer: Hawaii Western Management Group Commercial	$6.47
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Humana Medicare	$15.12
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$15.12
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: Ohana Health Plan Medicaid	$15.12
Rate for Payer: Ohana Health Plan Medicare	$15.12
Rate for Payer: UnitedHealthcare Medicaid	$8.95
Rate for Payer: UnitedHealthcare Medicare	$15.12
Rate for Payer: University Health Alliance Commercial	$16.74

Iron, Total DLS

Facility

$36.00

Service Code	HCPCS 83540
Hospital Charge Code	422835405
Hospital Revenue Code	301
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$23.40
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$32.40
Rate for Payer: MDX Hawaii PPO	$34.92

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC

Facility

$50,817.09

Service Code	MSDRG 062
Min. Negotiated Rate	$50,817.09
Max. Negotiated Rate	$50,817.09
Rate for Payer: Hawaii Medical Service Association Commercial	$50,817.09

Know your out-of-pocket cost for care.

All Charges