Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

pantoprazole 20 mg EC tab [KMC]

Facility

$3.00

Service Code	NDC 00093001198
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

pantoprazole 20 mg EC tab [KMC]

Facility

$3.00

Service Code	NDC 00093001198
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

pantoprazole 40 mg EC Tab [KMC]

Facility

$3.00

Service Code	NDC 60687073609
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

pantoprazole 40 mg EC Tab [KMC]

Facility

$3.00

Service Code	NDC 60687073609
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

pantoprazole 40 mg IV Inj [KMC]

Facility

$24.50

Service Code	HCPCS S0164
Hospital Revenue Code	637
Min. Negotiated Rate	$10.29
Max. Negotiated Rate	$23.77
Rate for Payer: AlohaCare Medicaid	$12.25
Rate for Payer: AlohaCare Medicare	$10.29
Rate for Payer: Cash Price	$15.92
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.54
Rate for Payer: Devoted Health Medicare	$10.29
Rate for Payer: Hawaii Medical Service Association Medicare	$10.29
Rate for Payer: Hawaii Western Management Group Commercial	$23.27
Rate for Payer: Health Management Network Commercial	$20.82
Rate for Payer: Humana Medicare	$10.29
Rate for Payer: Kaiser Permanente Commercial	$22.05
Rate for Payer: Kaiser Permanente Medicaid	$12.49
Rate for Payer: Kaiser Permanente Medicare	$10.29
Rate for Payer: MDX Hawaii PPO	$23.77
Rate for Payer: Ohana Health Plan Medicaid	$10.29
Rate for Payer: Ohana Health Plan Medicare	$10.29
Rate for Payer: UnitedHealthcare Medicare	$10.29
Rate for Payer: University Health Alliance Commercial	$17.86

pantoprazole 40 mg IV Inj [KMC]

Facility

$24.50

Service Code	HCPCS S0164
Hospital Revenue Code	637
Min. Negotiated Rate	$20.82
Max. Negotiated Rate	$23.77
Rate for Payer: Cash Price	$15.92
Rate for Payer: Health Management Network Commercial	$20.82
Rate for Payer: Kaiser Permanente Commercial	$22.05
Rate for Payer: MDX Hawaii PPO	$23.77

PAP DLS

Facility

$94.00

Service Code	HCPCS 88175
Hospital Charge Code	422881745
Hospital Revenue Code	311
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$61.10
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: MDX Hawaii PPO	$91.18

PAP DLS

Facility

$94.00

Service Code	HCPCS 88175
Hospital Charge Code	422881745
Hospital Revenue Code	311
Min. Negotiated Rate	$26.61
Max. Negotiated Rate	$91.18
Rate for Payer: AlohaCare Medicaid	$47.00
Rate for Payer: AlohaCare Medicare	$39.48
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$86.48
Rate for Payer: Devoted Health Medicare	$39.48
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$37.01
Rate for Payer: Hawaii Medical Service Association Commercial	$33.26
Rate for Payer: Hawaii Medical Service Association Medicare	$39.48
Rate for Payer: Hawaii Western Management Group Commercial	$26.61
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Humana Medicare	$39.48
Rate for Payer: Kaiser Permanente Commercial	$84.60
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: Kaiser Permanente Medicare	$39.48
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: Ohana Health Plan Medicaid	$39.48
Rate for Payer: Ohana Health Plan Medicare	$39.48
Rate for Payer: UnitedHealthcare Medicaid	$37.01
Rate for Payer: UnitedHealthcare Medicare	$39.48
Rate for Payer: University Health Alliance Commercial	$68.47

Paraffin Bath Charge

Facility

$42.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	432970180
Hospital Revenue Code	420
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$21.00
Rate for Payer: AlohaCare Medicare	$17.64
Rate for Payer: Cash Price	$27.30
Rate for Payer: Cash Price	$27.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$38.64
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$17.64
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$17.64
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$17.64
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$17.64
Rate for Payer: Ohana Health Plan Medicare	$17.64
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$17.64
Rate for Payer: University Health Alliance Commercial	$30.61

Paraffin Bath Charge

Facility

$51.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	426970180
Hospital Revenue Code	431
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$21.42
Rate for Payer: Cash Price	$33.15
Rate for Payer: Cash Price	$33.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.92
Rate for Payer: Devoted Health Medicare	$21.42
Rate for Payer: Hawaii Medical Service Association Medicare	$21.42
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$21.42
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$21.42
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$21.42
Rate for Payer: Ohana Health Plan Medicare	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$21.42
Rate for Payer: University Health Alliance Commercial	$37.17

Paraffin Bath Charge

Facility

$42.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	432970180
Hospital Revenue Code	420
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$27.30
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: MDX Hawaii PPO	$40.74

Paraffin Bath Charge

Facility

$51.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	426970180
Hospital Revenue Code	431
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

PARAFFIN BATH Occupational

Facility

$51.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	426970180
Hospital Revenue Code	431
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

PARAFFIN BATH Occupational

Facility

$51.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	426970180
Hospital Revenue Code	431
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$21.42
Rate for Payer: Cash Price	$33.15
Rate for Payer: Cash Price	$33.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.92
Rate for Payer: Devoted Health Medicare	$21.42
Rate for Payer: Hawaii Medical Service Association Medicare	$21.42
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$21.42
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$21.42
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$21.42
Rate for Payer: Ohana Health Plan Medicare	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$21.42
Rate for Payer: University Health Alliance Commercial	$37.17

PARAFFIN BATH Physical

Facility

$42.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	432970180
Hospital Revenue Code	420
Min. Negotiated Rate	$6.82
Max. Negotiated Rate	$40.74
Rate for Payer: AlohaCare Medicaid	$21.00
Rate for Payer: AlohaCare Medicare	$17.64
Rate for Payer: Cash Price	$27.30
Rate for Payer: Cash Price	$27.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$38.64
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$17.64
Rate for Payer: Hawaii Western Management Group Commercial	$39.90
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Humana Medicare	$17.64
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: Kaiser Permanente Medicaid	$21.42
Rate for Payer: Kaiser Permanente Medicare	$17.64
Rate for Payer: MDX Hawaii PPO	$40.74
Rate for Payer: Ohana Health Plan Medicaid	$17.64
Rate for Payer: Ohana Health Plan Medicare	$17.64
Rate for Payer: UnitedHealthcare Medicaid	$6.82
Rate for Payer: UnitedHealthcare Medicare	$17.64
Rate for Payer: University Health Alliance Commercial	$30.61

PARAFFIN BATH Physical

Facility

$42.00

Service Code	HCPCS 97018 GP
Hospital Charge Code	432970180
Hospital Revenue Code	420
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$40.74
Rate for Payer: Cash Price	$27.30
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$37.80
Rate for Payer: MDX Hawaii PPO	$40.74

PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1

Professional

Both

$307.00

Service Code	HCPCS 11055
Hospital Revenue Code	361
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$15.27
Rate for Payer: AlohaCare Medicare	$13.46
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$13.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$15.27
Rate for Payer: Hawaii Medical Service Association Commercial	$29.76
Rate for Payer: Hawaii Medical Service Association Medicare	$13.46
Rate for Payer: Hawaii Western Management Group Commercial	$21.32
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$16.15
Rate for Payer: Kaiser Permanente Medicaid	$16.15
Rate for Payer: Kaiser Permanente Medicare	$16.15
Rate for Payer: Ohana Health Plan Medicaid	$15.27
Rate for Payer: Ohana Health Plan Medicare	$13.46
Rate for Payer: UnitedHealthcare Medicaid	$15.27
Rate for Payer: UnitedHealthcare Medicare	$13.46
Rate for Payer: University Health Alliance Commercial	$16.47

PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4

Professional

Both

$307.00

Service Code	HCPCS 11056
Hospital Revenue Code	361
Min. Negotiated Rate	$19.42
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$21.60
Rate for Payer: AlohaCare Medicare	$19.42
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$19.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$21.60
Rate for Payer: Hawaii Medical Service Association Commercial	$42.02
Rate for Payer: Hawaii Medical Service Association Medicare	$19.42
Rate for Payer: Hawaii Western Management Group Commercial	$28.86
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$23.30
Rate for Payer: Kaiser Permanente Medicaid	$23.30
Rate for Payer: Kaiser Permanente Medicare	$23.30
Rate for Payer: Ohana Health Plan Medicaid	$21.60
Rate for Payer: Ohana Health Plan Medicare	$19.42
Rate for Payer: UnitedHealthcare Medicaid	$21.60
Rate for Payer: UnitedHealthcare Medicare	$19.42
Rate for Payer: University Health Alliance Commercial	$23.71

PARING/CUTTING BENIGN HYPERKERATOTIC LESION >4

Professional

Both

$540.00

Service Code	HCPCS 11057
Hospital Revenue Code	361
Min. Negotiated Rate	$25.05
Max. Negotiated Rate	$459.00
Rate for Payer: AlohaCare Medicaid	$28.31
Rate for Payer: AlohaCare Medicare	$25.05
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$25.05
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$28.31
Rate for Payer: Hawaii Medical Service Association Commercial	$54.05
Rate for Payer: Hawaii Medical Service Association Medicare	$25.05
Rate for Payer: Hawaii Western Management Group Commercial	$30.68
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$30.06
Rate for Payer: Kaiser Permanente Medicaid	$30.06
Rate for Payer: Kaiser Permanente Medicare	$30.06
Rate for Payer: Ohana Health Plan Medicaid	$28.31
Rate for Payer: Ohana Health Plan Medicare	$25.05
Rate for Payer: UnitedHealthcare Medicaid	$28.31
Rate for Payer: UnitedHealthcare Medicare	$25.05
Rate for Payer: University Health Alliance Commercial	$32.66

PARoxetine 10 mg Tab [KMC]

Facility

$10.67

Service Code	NDC 43547034703
Hospital Revenue Code	250
Min. Negotiated Rate	$9.07
Max. Negotiated Rate	$10.35
Rate for Payer: Cash Price	$6.94
Rate for Payer: Health Management Network Commercial	$9.07
Rate for Payer: Kaiser Permanente Commercial	$9.60
Rate for Payer: MDX Hawaii PPO	$10.35

PARoxetine 10 mg Tab [KMC]

Facility

$10.67

Service Code	NDC 43547034703
Hospital Revenue Code	250
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$10.35
Rate for Payer: AlohaCare Medicaid	$5.33
Rate for Payer: AlohaCare Medicare	$4.48
Rate for Payer: Cash Price	$6.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.82
Rate for Payer: Devoted Health Medicare	$4.48
Rate for Payer: Hawaii Medical Service Association Medicare	$4.48
Rate for Payer: Hawaii Western Management Group Commercial	$10.14
Rate for Payer: Health Management Network Commercial	$9.07
Rate for Payer: Humana Medicare	$4.48
Rate for Payer: Kaiser Permanente Commercial	$9.60
Rate for Payer: Kaiser Permanente Medicaid	$5.44
Rate for Payer: Kaiser Permanente Medicare	$4.48
Rate for Payer: MDX Hawaii PPO	$10.35
Rate for Payer: Ohana Health Plan Medicaid	$4.48
Rate for Payer: Ohana Health Plan Medicare	$4.48
Rate for Payer: UnitedHealthcare Medicaid	$6.40
Rate for Payer: UnitedHealthcare Medicare	$4.48
Rate for Payer: University Health Alliance Commercial	$7.78

PARoxetine 20 mg Tab [KMC]

Facility

$10.67

Service Code	NDC 16714018201
Hospital Revenue Code	250
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$10.35
Rate for Payer: AlohaCare Medicaid	$5.33
Rate for Payer: AlohaCare Medicare	$4.48
Rate for Payer: Cash Price	$6.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.82
Rate for Payer: Devoted Health Medicare	$4.48
Rate for Payer: Hawaii Medical Service Association Medicare	$4.48
Rate for Payer: Hawaii Western Management Group Commercial	$10.14
Rate for Payer: Health Management Network Commercial	$9.07
Rate for Payer: Humana Medicare	$4.48
Rate for Payer: Kaiser Permanente Commercial	$9.60
Rate for Payer: Kaiser Permanente Medicaid	$5.44
Rate for Payer: Kaiser Permanente Medicare	$4.48
Rate for Payer: MDX Hawaii PPO	$10.35
Rate for Payer: Ohana Health Plan Medicaid	$4.48
Rate for Payer: Ohana Health Plan Medicare	$4.48
Rate for Payer: UnitedHealthcare Medicaid	$6.40
Rate for Payer: UnitedHealthcare Medicare	$4.48
Rate for Payer: University Health Alliance Commercial	$7.78

PARoxetine 20 mg Tab [KMC]

Facility

$10.67

Service Code	NDC 16714018201
Hospital Revenue Code	250
Min. Negotiated Rate	$9.07
Max. Negotiated Rate	$10.35
Rate for Payer: Cash Price	$6.94
Rate for Payer: Health Management Network Commercial	$9.07
Rate for Payer: Kaiser Permanente Commercial	$9.60
Rate for Payer: MDX Hawaii PPO	$10.35

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$32,874.67

Service Code	MSDRG 543
Min. Negotiated Rate	$32,874.67
Max. Negotiated Rate	$32,874.67
Rate for Payer: Hawaii Medical Service Association Commercial	$32,874.67

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$32,874.67

Service Code	MSDRG 542
Min. Negotiated Rate	$32,874.67
Max. Negotiated Rate	$32,874.67
Rate for Payer: Hawaii Medical Service Association Commercial	$32,874.67

Know your out-of-pocket cost for care.

All Charges