Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

petrolatum topical 100% Ointment [KMC]

Facility

$0.39

Service Code	NDC 00521275000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.38
Rate for Payer: AlohaCare Medicaid	$0.20
Rate for Payer: AlohaCare Medicare	$0.16
Rate for Payer: Cash Price	$0.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.36
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Hawaii Medical Service Association Medicare	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$0.37
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Humana Medicare	$0.16
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: Kaiser Permanente Medicaid	$0.20
Rate for Payer: Kaiser Permanente Medicare	$0.16
Rate for Payer: MDX Hawaii PPO	$0.38
Rate for Payer: Ohana Health Plan Medicaid	$0.16
Rate for Payer: Ohana Health Plan Medicare	$0.16
Rate for Payer: UnitedHealthcare Medicaid	$0.23
Rate for Payer: UnitedHealthcare Medicare	$0.16
Rate for Payer: University Health Alliance Commercial	$0.28

petrolatum topical 100% Ointment [KMC]

Facility

$0.39

Service Code	NDC 00521275000
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Management Network Commercial	$0.33
Rate for Payer: Kaiser Permanente Commercial	$0.35
Rate for Payer: MDX Hawaii PPO	$0.38

PF FLX GLOVE W/ELSTC FGR Occupational

Facility

$207.00

Service Code	HCPCS L3912
Hospital Charge Code	432L39120
Hospital Revenue Code	274
Min. Negotiated Rate	$67.78
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$86.94
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$190.44
Rate for Payer: Devoted Health Medicare	$86.94
Rate for Payer: Hawaii Medical Service Association Medicare	$86.94
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$86.94
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$86.94
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$86.94
Rate for Payer: Ohana Health Plan Medicare	$86.94
Rate for Payer: UnitedHealthcare Medicaid	$67.78
Rate for Payer: UnitedHealthcare Medicare	$86.94
Rate for Payer: University Health Alliance Commercial	$115.92

PF FLX GLOVE W/ELSTC FGR Occupational

Facility

$207.00

Service Code	HCPCS L3912
Hospital Charge Code	432L39120
Hospital Revenue Code	274
Min. Negotiated Rate	$115.92
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Hawaii Western Management Group Commercial	$144.90
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$115.92

PHARMACOLOGIC OSTEOPOROSIS THERAPY PRESCRIBED

Professional

Both

$0.01

Service Code	HCPCS 4005F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

phenazopyridine 95 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 49348007644
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

phenazopyridine 95 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 49348007644
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

PHENobarbital 20 mg/5 mL Oral Elix [KMC]

Facility

$0.85

Service Code	NDC 16571033016
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.55
Rate for Payer: Health Management Network Commercial	$0.72
Rate for Payer: Kaiser Permanente Commercial	$0.77
Rate for Payer: MDX Hawaii PPO	$0.82

PHENobarbital 20 mg/5 mL Oral Elix [KMC]

Facility

$0.85

Service Code	NDC 16571033016
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.82
Rate for Payer: AlohaCare Medicaid	$0.43
Rate for Payer: AlohaCare Medicare	$0.36
Rate for Payer: Cash Price	$0.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.78
Rate for Payer: Devoted Health Medicare	$0.36
Rate for Payer: Hawaii Medical Service Association Medicare	$0.36
Rate for Payer: Hawaii Western Management Group Commercial	$0.81
Rate for Payer: Health Management Network Commercial	$0.72
Rate for Payer: Humana Medicare	$0.36
Rate for Payer: Kaiser Permanente Commercial	$0.77
Rate for Payer: Kaiser Permanente Medicaid	$0.43
Rate for Payer: Kaiser Permanente Medicare	$0.36
Rate for Payer: MDX Hawaii PPO	$0.82
Rate for Payer: Ohana Health Plan Medicaid	$0.36
Rate for Payer: Ohana Health Plan Medicare	$0.36
Rate for Payer: UnitedHealthcare Medicaid	$0.51
Rate for Payer: UnitedHealthcare Medicare	$0.36
Rate for Payer: University Health Alliance Commercial	$0.62

PHENobarbital 64.8 mg Tab [KMC]

Facility

$3.35

Service Code	NDC 16571066701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$3.25
Rate for Payer: AlohaCare Medicaid	$1.68
Rate for Payer: AlohaCare Medicare	$1.41
Rate for Payer: Cash Price	$2.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.08
Rate for Payer: Devoted Health Medicare	$1.41
Rate for Payer: Hawaii Medical Service Association Medicare	$1.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.18
Rate for Payer: Health Management Network Commercial	$2.85
Rate for Payer: Humana Medicare	$1.41
Rate for Payer: Kaiser Permanente Commercial	$3.02
Rate for Payer: Kaiser Permanente Medicaid	$1.71
Rate for Payer: Kaiser Permanente Medicare	$1.41
Rate for Payer: MDX Hawaii PPO	$3.25
Rate for Payer: Ohana Health Plan Medicaid	$1.41
Rate for Payer: Ohana Health Plan Medicare	$1.41
Rate for Payer: UnitedHealthcare Medicaid	$2.01
Rate for Payer: UnitedHealthcare Medicare	$1.41
Rate for Payer: University Health Alliance Commercial	$2.44

PHENobarbital 64.8 mg Tab [KMC]

Facility

$3.35

Service Code	NDC 16571066701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$2.18
Rate for Payer: Health Management Network Commercial	$2.85
Rate for Payer: Kaiser Permanente Commercial	$3.02
Rate for Payer: MDX Hawaii PPO	$3.25

Phenobarbital DLS

Facility

$251.00

Service Code	HCPCS 80184
Hospital Charge Code	422801845
Hospital Revenue Code	301
Min. Negotiated Rate	$213.35
Max. Negotiated Rate	$243.47
Rate for Payer: Cash Price	$163.15
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: MDX Hawaii PPO	$243.47

Phenobarbital DLS

Facility

$251.00

Service Code	HCPCS 80184
Hospital Charge Code	422801845
Hospital Revenue Code	301
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$243.47
Rate for Payer: AlohaCare Medicaid	$125.50
Rate for Payer: AlohaCare Medicare	$105.42
Rate for Payer: Cash Price	$163.15
Rate for Payer: Cash Price	$163.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$230.92
Rate for Payer: Devoted Health Medicare	$105.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$15.83
Rate for Payer: Hawaii Medical Service Association Commercial	$19.12
Rate for Payer: Hawaii Medical Service Association Medicare	$105.42
Rate for Payer: Hawaii Western Management Group Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$213.35
Rate for Payer: Humana Medicare	$105.42
Rate for Payer: Kaiser Permanente Commercial	$225.90
Rate for Payer: Kaiser Permanente Medicaid	$128.01
Rate for Payer: Kaiser Permanente Medicare	$105.42
Rate for Payer: MDX Hawaii PPO	$243.47
Rate for Payer: Ohana Health Plan Medicaid	$105.42
Rate for Payer: Ohana Health Plan Medicare	$105.42
Rate for Payer: UnitedHealthcare Medicaid	$15.83
Rate for Payer: UnitedHealthcare Medicare	$105.42
Rate for Payer: University Health Alliance Commercial	$29.62

phenylephrine 0.25% rectal ointment [KMC]

Facility

$0.25

Service Code	NDC 49348019878
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Management Network Commercial	$0.21
Rate for Payer: Kaiser Permanente Commercial	$0.23
Rate for Payer: MDX Hawaii PPO	$0.24

phenylephrine 0.25% rectal ointment [KMC]

Facility

$0.25

Service Code	NDC 49348019878
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: AlohaCare Medicaid	$0.13
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$0.16
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.23
Rate for Payer: Devoted Health Medicare	$0.11
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Hawaii Western Management Group Commercial	$0.24
Rate for Payer: Health Management Network Commercial	$0.21
Rate for Payer: Humana Medicare	$0.11
Rate for Payer: Kaiser Permanente Commercial	$0.23
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.11
Rate for Payer: MDX Hawaii PPO	$0.24
Rate for Payer: Ohana Health Plan Medicaid	$0.11
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicaid	$0.15
Rate for Payer: UnitedHealthcare Medicare	$0.11
Rate for Payer: University Health Alliance Commercial	$0.18

phenylephrine 0.25% suppository [KMC]

Facility

$3.00

Service Code	NDC 00573288310
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

phenylephrine 0.25% suppository [KMC]

Facility

$3.00

Service Code	NDC 00573288310
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

phenylephrine 10 mg/mL Soln [KMC]

Facility

$15.36

Service Code	HCPCS J2370
Hospital Revenue Code	636
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$14.90
Rate for Payer: AlohaCare Medicaid	$7.68
Rate for Payer: AlohaCare Medicare	$6.45
Rate for Payer: Cash Price	$9.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$14.13
Rate for Payer: Devoted Health Medicare	$6.45
Rate for Payer: Hawaii Medical Service Association Medicare	$6.45
Rate for Payer: Hawaii Western Management Group Commercial	$14.59
Rate for Payer: Health Management Network Commercial	$13.06
Rate for Payer: Humana Medicare	$6.45
Rate for Payer: Kaiser Permanente Commercial	$13.82
Rate for Payer: Kaiser Permanente Medicaid	$7.83
Rate for Payer: Kaiser Permanente Medicare	$6.45
Rate for Payer: MDX Hawaii PPO	$14.90
Rate for Payer: Ohana Health Plan Medicaid	$6.45
Rate for Payer: Ohana Health Plan Medicare	$6.45
Rate for Payer: UnitedHealthcare Medicaid	$9.22
Rate for Payer: UnitedHealthcare Medicare	$6.45
Rate for Payer: University Health Alliance Commercial	$11.20

phenylephrine 10 mg/mL Soln [KMC]

Facility

$15.36

Service Code	HCPCS J2370
Hospital Revenue Code	636
Min. Negotiated Rate	$13.06
Max. Negotiated Rate	$14.90
Rate for Payer: Cash Price	$9.98
Rate for Payer: Health Management Network Commercial	$13.06
Rate for Payer: Kaiser Permanente Commercial	$13.82
Rate for Payer: MDX Hawaii PPO	$14.90

phenytoin 100 mg/4 mL Oral Susp [KMC]

Facility

$0.79

Service Code	NDC 00472500208
Hospital Revenue Code	250
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Management Network Commercial	$0.67
Rate for Payer: Kaiser Permanente Commercial	$0.71
Rate for Payer: MDX Hawaii PPO	$0.77

phenytoin 100 mg/4 mL Oral Susp [KMC]

Facility

$0.79

Service Code	NDC 00472500208
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.77
Rate for Payer: AlohaCare Medicaid	$0.40
Rate for Payer: AlohaCare Medicare	$0.33
Rate for Payer: Cash Price	$0.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.73
Rate for Payer: Devoted Health Medicare	$0.33
Rate for Payer: Hawaii Medical Service Association Medicare	$0.33
Rate for Payer: Hawaii Western Management Group Commercial	$0.75
Rate for Payer: Health Management Network Commercial	$0.67
Rate for Payer: Humana Medicare	$0.33
Rate for Payer: Kaiser Permanente Commercial	$0.71
Rate for Payer: Kaiser Permanente Medicaid	$0.40
Rate for Payer: Kaiser Permanente Medicare	$0.33
Rate for Payer: MDX Hawaii PPO	$0.77
Rate for Payer: Ohana Health Plan Medicaid	$0.33
Rate for Payer: Ohana Health Plan Medicare	$0.33
Rate for Payer: UnitedHealthcare Medicaid	$0.47
Rate for Payer: UnitedHealthcare Medicare	$0.33
Rate for Payer: University Health Alliance Commercial	$0.58

phenytoin 100 mg ER Cap [KMC]

Facility

$3.00

Service Code	NDC 42291077201
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

phenytoin 100 mg ER Cap [KMC]

Facility

$3.00

Service Code	NDC 42291077201
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

phenytoin 50 mg Chew Tab [KMC]

Facility

$3.00

Service Code	NDC 51672414601
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

phenytoin 50 mg Chew Tab [KMC]

Facility

$3.00

Service Code	NDC 51672414601
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

Know your out-of-pocket cost for care.

All Charges