Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Penicillin G Potassium 5,000,000 units REC [KMC]

Facility

$61.06

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$51.90
Max. Negotiated Rate	$59.23
Rate for Payer: Cash Price	$39.69
Rate for Payer: Health Management Network Commercial	$51.90
Rate for Payer: Kaiser Permanente Commercial	$54.95
Rate for Payer: MDX Hawaii PPO	$59.23

Penicillin G Potassium 5,000,000 units REC [KMC]

Facility

$61.06

Service Code	HCPCS J2540
Hospital Revenue Code	636
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$59.23
Rate for Payer: AlohaCare Medicaid	$30.53
Rate for Payer: AlohaCare Medicare	$25.65
Rate for Payer: Cash Price	$39.69
Rate for Payer: Cash Price	$39.69
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$56.18
Rate for Payer: Devoted Health Medicare	$25.65
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.88
Rate for Payer: Hawaii Medical Service Association Medicare	$25.65
Rate for Payer: Hawaii Western Management Group Commercial	$58.01
Rate for Payer: Health Management Network Commercial	$51.90
Rate for Payer: Humana Medicare	$25.65
Rate for Payer: Kaiser Permanente Commercial	$54.95
Rate for Payer: Kaiser Permanente Medicaid	$31.14
Rate for Payer: Kaiser Permanente Medicare	$25.65
Rate for Payer: MDX Hawaii PPO	$59.23
Rate for Payer: Ohana Health Plan Medicaid	$25.65
Rate for Payer: Ohana Health Plan Medicare	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$36.64
Rate for Payer: UnitedHealthcare Medicare	$25.65
Rate for Payer: University Health Alliance Commercial	$44.51

Penicillin G Sodium 5,000,000 units REC [KMC]

Facility

$191.64

Service Code	NDC 00781615394
Hospital Revenue Code	250
Min. Negotiated Rate	$162.89
Max. Negotiated Rate	$185.89
Rate for Payer: Cash Price	$124.57
Rate for Payer: Health Management Network Commercial	$162.89
Rate for Payer: Kaiser Permanente Commercial	$172.48
Rate for Payer: MDX Hawaii PPO	$185.89

Penicillin G Sodium 5,000,000 units REC [KMC]

Facility

$191.64

Service Code	NDC 00781615394
Hospital Revenue Code	250
Min. Negotiated Rate	$80.49
Max. Negotiated Rate	$185.89
Rate for Payer: AlohaCare Medicaid	$95.82
Rate for Payer: AlohaCare Medicare	$80.49
Rate for Payer: Cash Price	$124.57
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$176.31
Rate for Payer: Devoted Health Medicare	$80.49
Rate for Payer: Hawaii Medical Service Association Medicare	$80.49
Rate for Payer: Hawaii Western Management Group Commercial	$182.06
Rate for Payer: Health Management Network Commercial	$162.89
Rate for Payer: Humana Medicare	$80.49
Rate for Payer: Kaiser Permanente Commercial	$172.48
Rate for Payer: Kaiser Permanente Medicaid	$97.74
Rate for Payer: Kaiser Permanente Medicare	$80.49
Rate for Payer: MDX Hawaii PPO	$185.89
Rate for Payer: Ohana Health Plan Medicaid	$80.49
Rate for Payer: Ohana Health Plan Medicare	$80.49
Rate for Payer: UnitedHealthcare Medicaid	$114.98
Rate for Payer: UnitedHealthcare Medicare	$80.49
Rate for Payer: University Health Alliance Commercial	$139.69

Penicillin V Potassium 500 mg Tab [KMC]

Facility

$5.12

Service Code	NDC 16714023501
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$4.97
Rate for Payer: AlohaCare Medicaid	$2.56
Rate for Payer: AlohaCare Medicare	$2.15
Rate for Payer: Cash Price	$3.33
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.71
Rate for Payer: Devoted Health Medicare	$2.15
Rate for Payer: Hawaii Medical Service Association Medicare	$2.15
Rate for Payer: Hawaii Western Management Group Commercial	$4.86
Rate for Payer: Health Management Network Commercial	$4.35
Rate for Payer: Humana Medicare	$2.15
Rate for Payer: Kaiser Permanente Commercial	$4.61
Rate for Payer: Kaiser Permanente Medicaid	$2.61
Rate for Payer: Kaiser Permanente Medicare	$2.15
Rate for Payer: MDX Hawaii PPO	$4.97
Rate for Payer: Ohana Health Plan Medicaid	$2.15
Rate for Payer: Ohana Health Plan Medicare	$2.15
Rate for Payer: UnitedHealthcare Medicaid	$3.07
Rate for Payer: UnitedHealthcare Medicare	$2.15
Rate for Payer: University Health Alliance Commercial	$3.73

Penicillin V Potassium 500 mg Tab [KMC]

Facility

$5.12

Service Code	NDC 16714023501
Hospital Revenue Code	250
Min. Negotiated Rate	$4.35
Max. Negotiated Rate	$4.97
Rate for Payer: Cash Price	$3.33
Rate for Payer: Health Management Network Commercial	$4.35
Rate for Payer: Kaiser Permanente Commercial	$4.61
Rate for Payer: MDX Hawaii PPO	$4.97

PENIS PROCEDURES WITH CC/MCC

Facility

$24,958.21

Service Code	MSDRG 709
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$24,958.21

Service Code	MSDRG 710
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

PENROSE DRAIN 1/4"

Facility

$17.00

Hospital Charge Code	8238
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

PENROSE DRAIN 1/4"

Facility

$17.00

Hospital Charge Code	8238
Hospital Revenue Code	270
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$7.14
Rate for Payer: Cash Price	$11.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.64
Rate for Payer: Devoted Health Medicare	$7.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7.14
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$7.14
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$7.14
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$7.14
Rate for Payer: Ohana Health Plan Medicare	$7.14
Rate for Payer: UnitedHealthcare Medicare	$7.14
Rate for Payer: University Health Alliance Commercial	$12.39

pentoxifylline 400 mg ER tab [KMC]

Facility

$4.56

Service Code	NDC 60505003306
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$4.42
Rate for Payer: Cash Price	$2.96
Rate for Payer: Health Management Network Commercial	$3.88
Rate for Payer: Kaiser Permanente Commercial	$4.10
Rate for Payer: MDX Hawaii PPO	$4.42

pentoxifylline 400 mg ER tab [KMC]

Facility

$4.56

Service Code	NDC 60505003306
Hospital Revenue Code	250
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$4.42
Rate for Payer: AlohaCare Medicaid	$2.28
Rate for Payer: AlohaCare Medicare	$1.92
Rate for Payer: Cash Price	$2.96
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.20
Rate for Payer: Devoted Health Medicare	$1.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1.92
Rate for Payer: Hawaii Western Management Group Commercial	$4.33
Rate for Payer: Health Management Network Commercial	$3.88
Rate for Payer: Humana Medicare	$1.92
Rate for Payer: Kaiser Permanente Commercial	$4.10
Rate for Payer: Kaiser Permanente Medicaid	$2.33
Rate for Payer: Kaiser Permanente Medicare	$1.92
Rate for Payer: MDX Hawaii PPO	$4.42
Rate for Payer: Ohana Health Plan Medicaid	$1.92
Rate for Payer: Ohana Health Plan Medicare	$1.92
Rate for Payer: UnitedHealthcare Medicaid	$2.74
Rate for Payer: UnitedHealthcare Medicare	$1.92
Rate for Payer: University Health Alliance Commercial	$3.32

perampanel 4 mg Tab [KMC]

Facility

$130.56

Service Code	NDC 62856027430
Hospital Revenue Code	250
Min. Negotiated Rate	$54.84
Max. Negotiated Rate	$126.64
Rate for Payer: AlohaCare Medicaid	$65.28
Rate for Payer: AlohaCare Medicare	$54.84
Rate for Payer: Cash Price	$84.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$120.12
Rate for Payer: Devoted Health Medicare	$54.84
Rate for Payer: Hawaii Medical Service Association Medicare	$54.84
Rate for Payer: Hawaii Western Management Group Commercial	$124.03
Rate for Payer: Health Management Network Commercial	$110.98
Rate for Payer: Humana Medicare	$54.84
Rate for Payer: Kaiser Permanente Commercial	$117.50
Rate for Payer: Kaiser Permanente Medicaid	$66.59
Rate for Payer: Kaiser Permanente Medicare	$54.84
Rate for Payer: MDX Hawaii PPO	$126.64
Rate for Payer: Ohana Health Plan Medicaid	$54.84
Rate for Payer: Ohana Health Plan Medicare	$54.84
Rate for Payer: UnitedHealthcare Medicaid	$78.34
Rate for Payer: UnitedHealthcare Medicare	$54.84
Rate for Payer: University Health Alliance Commercial	$95.17

perampanel 4 mg Tab [KMC]

Facility

$130.56

Service Code	NDC 62856027430
Hospital Revenue Code	250
Min. Negotiated Rate	$110.98
Max. Negotiated Rate	$126.64
Rate for Payer: Cash Price	$84.86
Rate for Payer: Health Management Network Commercial	$110.98
Rate for Payer: Kaiser Permanente Commercial	$117.50
Rate for Payer: MDX Hawaii PPO	$126.64

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$53,400.61

Service Code	MSDRG 273
Min. Negotiated Rate	$53,400.61
Max. Negotiated Rate	$53,400.61
Rate for Payer: Hawaii Medical Service Association Commercial	$53,400.61

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC

Facility

$37,591.37

Service Code	MSDRG 274
Min. Negotiated Rate	$37,591.37
Max. Negotiated Rate	$37,591.37
Rate for Payer: Hawaii Medical Service Association Commercial	$37,591.37

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES

Facility

$57,050.71

Service Code	MSDRG 321
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$40,483.02

Service Code	MSDRG 322
Min. Negotiated Rate	$40,483.02
Max. Negotiated Rate	$40,483.02
Rate for Payer: Hawaii Medical Service Association Commercial	$40,483.02

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC

Facility

$47,996.55

Service Code	MSDRG 250
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC

Facility

$35,742.62

Service Code	MSDRG 251
Min. Negotiated Rate	$35,742.62
Max. Negotiated Rate	$35,742.62
Rate for Payer: Hawaii Medical Service Association Commercial	$35,742.62

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC

Facility

$57,050.71

Service Code	MSDRG 359
Min. Negotiated Rate	$57,050.71
Max. Negotiated Rate	$57,050.71
Rate for Payer: Hawaii Medical Service Association Commercial	$57,050.71

PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC

Facility

$40,483.02

Service Code	MSDRG 360
Min. Negotiated Rate	$40,483.02
Max. Negotiated Rate	$40,483.02
Rate for Payer: Hawaii Medical Service Association Commercial	$40,483.02

PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE

Facility

$47,996.55

Service Code	MSDRG 318
Min. Negotiated Rate	$47,996.55
Max. Negotiated Rate	$47,996.55
Rate for Payer: Hawaii Medical Service Association Commercial	$47,996.55

PERICARDIOCENTESIS INITIAL CHARGE

Facility

$2,477.00

Service Code	HCPCS 33010
Hospital Charge Code	440330100
Hospital Revenue Code	450
Min. Negotiated Rate	$2,105.45
Max. Negotiated Rate	$2,402.69
Rate for Payer: Cash Price	$1,610.05
Rate for Payer: Health Management Network Commercial	$2,105.45
Rate for Payer: Kaiser Permanente Commercial	$2,229.30
Rate for Payer: MDX Hawaii PPO	$2,402.69

PERICARDIOCENTESIS INITIAL CHARGE

Facility

$2,477.00

Service Code	HCPCS 33010
Hospital Charge Code	440330100
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$2,402.69
Rate for Payer: AlohaCare Medicaid	$1,238.50
Rate for Payer: AlohaCare Medicare	$1,040.34
Rate for Payer: Cash Price	$1,610.05
Rate for Payer: Cash Price	$1,610.05
Rate for Payer: Cash Price	$1,610.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,278.84
Rate for Payer: Devoted Health Medicare	$1,040.34
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	$1,040.34
Rate for Payer: Hawaii Western Management Group Commercial	$2,353.15
Rate for Payer: Health Management Network Commercial	$2,105.45
Rate for Payer: Humana Medicare	$1,040.34
Rate for Payer: Kaiser Permanente Commercial	$2,229.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,040.34
Rate for Payer: MDX Hawaii PPO	$2,402.69
Rate for Payer: Ohana Health Plan Medicaid	$1,040.34
Rate for Payer: Ohana Health Plan Medicare	$1,040.34
Rate for Payer: UnitedHealthcare Medicare	$1,040.34
Rate for Payer: University Health Alliance Commercial	$1,805.49

Know your out-of-pocket cost for care.

All Charges