Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Phonophoresis Charge

Facility

$179.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	426970350
Hospital Revenue Code	430
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

Phonophoresis Charge

Facility

$179.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	426970350
Hospital Revenue Code	430
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

Phonophoresis Charge

Facility

$179.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	432970350
Hospital Revenue Code	420
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

Phonophoresis Charge

Facility

$179.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	432970350
Hospital Revenue Code	420
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

Phosphorus DLS

Facility

$69.00

Service Code	HCPCS 84100
Hospital Charge Code	422841005
Hospital Revenue Code	301
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.56
Rate for Payer: Hawaii Medical Service Association Commercial	$5.92
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$4.74
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$12.27

Phosphorus DLS

Facility

$69.00

Service Code	HCPCS 84100
Hospital Charge Code	422841005
Hospital Revenue Code	301
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

Phosphorus (K, Na) 250-280-160 mg packets [KMC]

Facility

$3.00

Service Code	NDC 60258000601
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

Phosphorus (K, Na) 250-280-160 mg packets [KMC]

Facility

$3.00

Service Code	NDC 60258000601
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

Phosphorus Level

Facility

$69.00

Service Code	HCPCS 84100
Hospital Charge Code	422841000
Hospital Revenue Code	301
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

Phosphorus Level

Facility

$69.00

Service Code	HCPCS 84100
Hospital Charge Code	422841000
Hospital Revenue Code	301
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$28.98
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.56
Rate for Payer: Hawaii Medical Service Association Commercial	$5.92
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$4.74
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$28.98
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$28.98
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$28.98
Rate for Payer: Ohana Health Plan Medicare	$28.98
Rate for Payer: UnitedHealthcare Medicaid	$6.56
Rate for Payer: UnitedHealthcare Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$12.27

Phosphorus (Na, K) 250-298-45 mg tablet [KMC]

Facility

$3.00

Service Code	NDC 69367025001
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

Phosphorus (Na, K) 250-298-45 mg tablet [KMC]

Facility

$3.00

Service Code	NDC 69367025001
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

PHY PERFORM TST EA 15 MIN Occupational

Facility

$223.00

Service Code	HCPCS 97750 GO
Hospital Charge Code	426977500
Hospital Revenue Code	430
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$93.66
Rate for Payer: Cash Price	$144.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$205.16
Rate for Payer: Devoted Health Medicare	$93.66
Rate for Payer: Hawaii Medical Service Association Medicare	$93.66
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$93.66
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$93.66
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$93.66
Rate for Payer: Ohana Health Plan Medicare	$93.66
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$93.66
Rate for Payer: University Health Alliance Commercial	$162.54

PHY PERFORM TST EA 15 MIN Occupational

Facility

$223.00

Service Code	HCPCS 97750 GO
Hospital Charge Code	426977500
Hospital Revenue Code	430
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$144.95
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

PHY PERFORM TST EA 15 MIN Physical

Facility

$223.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	432977500
Hospital Revenue Code	420
Min. Negotiated Rate	$189.55
Max. Negotiated Rate	$216.31
Rate for Payer: Cash Price	$144.95
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: MDX Hawaii PPO	$216.31

PHY PERFORM TST EA 15 MIN Physical

Facility

$223.00

Service Code	HCPCS 97750 GP
Hospital Charge Code	432977500
Hospital Revenue Code	420
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$216.31
Rate for Payer: AlohaCare Medicaid	$111.50
Rate for Payer: AlohaCare Medicare	$93.66
Rate for Payer: Cash Price	$144.95
Rate for Payer: Cash Price	$144.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$205.16
Rate for Payer: Devoted Health Medicare	$93.66
Rate for Payer: Hawaii Medical Service Association Medicare	$93.66
Rate for Payer: Hawaii Western Management Group Commercial	$211.85
Rate for Payer: Health Management Network Commercial	$189.55
Rate for Payer: Humana Medicare	$93.66
Rate for Payer: Kaiser Permanente Commercial	$200.70
Rate for Payer: Kaiser Permanente Medicaid	$113.73
Rate for Payer: Kaiser Permanente Medicare	$93.66
Rate for Payer: MDX Hawaii PPO	$216.31
Rate for Payer: Ohana Health Plan Medicaid	$93.66
Rate for Payer: Ohana Health Plan Medicare	$93.66
Rate for Payer: UnitedHealthcare Medicaid	$19.83
Rate for Payer: UnitedHealthcare Medicare	$93.66
Rate for Payer: University Health Alliance Commercial	$162.54

PHYSICAL PERFORMANCE TEST/MEAS W/REPRT EA 15 MIN

Professional

Both

$213.00

Service Code	HCPCS 97750
Hospital Revenue Code	420
Min. Negotiated Rate	$23.50
Max. Negotiated Rate	$181.05
Rate for Payer: AlohaCare Medicaid	$36.58
Rate for Payer: AlohaCare Medicare	$36.11
Rate for Payer: Cash Price	$138.45
Rate for Payer: Cash Price	$138.45
Rate for Payer: Devoted Health Medicare	$36.11
Rate for Payer: Hawaii Medical Service Association Medicare	$36.11
Rate for Payer: Hawaii Western Management Group Commercial	$23.50
Rate for Payer: Health Management Network Commercial	$181.05
Rate for Payer: Kaiser Permanente Commercial	$43.33
Rate for Payer: Kaiser Permanente Medicaid	$43.33
Rate for Payer: Kaiser Permanente Medicare	$43.33
Rate for Payer: Ohana Health Plan Medicaid	$36.58
Rate for Payer: Ohana Health Plan Medicare	$36.11
Rate for Payer: UnitedHealthcare Medicaid	$36.58
Rate for Payer: UnitedHealthcare Medicare	$36.11

PHYSICAL THERAPY EVALUATION HIGH COMPLEX 45 MINS

Professional

Both

$327.00

Service Code	HCPCS 97163
Hospital Revenue Code	420
Min. Negotiated Rate	$54.45
Max. Negotiated Rate	$277.95
Rate for Payer: AlohaCare Medicaid	$106.70
Rate for Payer: AlohaCare Medicare	$104.04
Rate for Payer: Cash Price	$212.55
Rate for Payer: Cash Price	$212.55
Rate for Payer: Devoted Health Medicare	$104.04
Rate for Payer: Hawaii Medical Service Association Medicare	$104.04
Rate for Payer: Hawaii Western Management Group Commercial	$54.45
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Kaiser Permanente Commercial	$124.85
Rate for Payer: Kaiser Permanente Medicaid	$124.85
Rate for Payer: Kaiser Permanente Medicare	$124.85
Rate for Payer: Ohana Health Plan Medicaid	$106.70
Rate for Payer: Ohana Health Plan Medicare	$104.04
Rate for Payer: UnitedHealthcare Medicaid	$106.70
Rate for Payer: UnitedHealthcare Medicare	$104.04

PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS

Professional

Both

$327.00

Service Code	HCPCS 97161
Hospital Revenue Code	420
Min. Negotiated Rate	$54.45
Max. Negotiated Rate	$277.95
Rate for Payer: AlohaCare Medicaid	$106.70
Rate for Payer: AlohaCare Medicare	$104.04
Rate for Payer: Cash Price	$212.55
Rate for Payer: Cash Price	$212.55
Rate for Payer: Devoted Health Medicare	$104.04
Rate for Payer: Hawaii Medical Service Association Medicare	$104.04
Rate for Payer: Hawaii Western Management Group Commercial	$54.45
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Kaiser Permanente Commercial	$124.85
Rate for Payer: Kaiser Permanente Medicaid	$124.85
Rate for Payer: Kaiser Permanente Medicare	$124.85
Rate for Payer: Ohana Health Plan Medicaid	$106.70
Rate for Payer: Ohana Health Plan Medicare	$104.04
Rate for Payer: UnitedHealthcare Medicaid	$106.70
Rate for Payer: UnitedHealthcare Medicare	$104.04

PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS

Professional

Both

$327.00

Service Code	HCPCS 97162
Hospital Revenue Code	420
Min. Negotiated Rate	$54.45
Max. Negotiated Rate	$277.95
Rate for Payer: AlohaCare Medicaid	$106.70
Rate for Payer: AlohaCare Medicare	$104.04
Rate for Payer: Cash Price	$212.55
Rate for Payer: Cash Price	$212.55
Rate for Payer: Devoted Health Medicare	$104.04
Rate for Payer: Hawaii Medical Service Association Medicare	$104.04
Rate for Payer: Hawaii Western Management Group Commercial	$54.45
Rate for Payer: Health Management Network Commercial	$277.95
Rate for Payer: Kaiser Permanente Commercial	$124.85
Rate for Payer: Kaiser Permanente Medicaid	$124.85
Rate for Payer: Kaiser Permanente Medicare	$124.85
Rate for Payer: Ohana Health Plan Medicaid	$106.70
Rate for Payer: Ohana Health Plan Medicare	$104.04
Rate for Payer: UnitedHealthcare Medicaid	$106.70
Rate for Payer: UnitedHealthcare Medicare	$104.04

PHYSICAL THERAPY RE-EVAL EST PLAN CARE 20 MINS

Professional

Both

$225.00

Service Code	HCPCS 97164
Hospital Revenue Code	420
Min. Negotiated Rate	$22.70
Max. Negotiated Rate	$191.25
Rate for Payer: AlohaCare Medicaid	$74.59
Rate for Payer: AlohaCare Medicare	$72.13
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Devoted Health Medicare	$72.13
Rate for Payer: Hawaii Medical Service Association Medicare	$72.13
Rate for Payer: Hawaii Western Management Group Commercial	$22.70
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$86.56
Rate for Payer: Kaiser Permanente Medicaid	$86.56
Rate for Payer: Kaiser Permanente Medicare	$86.56
Rate for Payer: Ohana Health Plan Medicaid	$74.59
Rate for Payer: Ohana Health Plan Medicare	$72.13
Rate for Payer: UnitedHealthcare Medicaid	$74.59
Rate for Payer: UnitedHealthcare Medicare	$72.13

PHYS/QHP SVCS OP PULM REHAB W/CONT OXIMTRY MNTR

Professional

Both

$182.00

Service Code	HCPCS 94626
Hospital Revenue Code	410
Min. Negotiated Rate	$23.86
Max. Negotiated Rate	$154.70
Rate for Payer: AlohaCare Medicaid	$27.22
Rate for Payer: AlohaCare Medicare	$23.86
Rate for Payer: Cash Price	$118.30
Rate for Payer: Cash Price	$118.30
Rate for Payer: Devoted Health Medicare	$23.86
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$27.22
Rate for Payer: Hawaii Medical Service Association Commercial	$42.27
Rate for Payer: Hawaii Medical Service Association Medicare	$23.86
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Kaiser Permanente Commercial	$28.63
Rate for Payer: Kaiser Permanente Medicaid	$28.63
Rate for Payer: Kaiser Permanente Medicare	$28.63
Rate for Payer: Ohana Health Plan Medicaid	$27.22
Rate for Payer: Ohana Health Plan Medicare	$23.86
Rate for Payer: UnitedHealthcare Medicaid	$27.22
Rate for Payer: UnitedHealthcare Medicare	$23.86
Rate for Payer: University Health Alliance Commercial	$29.19

PHYS/QHP SVCS OP PULM REHAB WO CONT OXIMTRY MNTR

Professional

Both

$195.00

Service Code	HCPCS 94625
Hospital Revenue Code	410
Min. Negotiated Rate	$16.03
Max. Negotiated Rate	$165.75
Rate for Payer: AlohaCare Medicaid	$18.47
Rate for Payer: AlohaCare Medicare	$16.03
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Devoted Health Medicare	$16.03
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.47
Rate for Payer: Hawaii Medical Service Association Commercial	$29.10
Rate for Payer: Hawaii Medical Service Association Medicare	$16.03
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$19.24
Rate for Payer: Kaiser Permanente Medicaid	$19.24
Rate for Payer: Kaiser Permanente Medicare	$19.24
Rate for Payer: Ohana Health Plan Medicaid	$18.47
Rate for Payer: Ohana Health Plan Medicare	$16.03
Rate for Payer: UnitedHealthcare Medicaid	$18.47
Rate for Payer: UnitedHealthcare Medicare	$16.03
Rate for Payer: University Health Alliance Commercial	$19.95

phytonadione 10 mg/mL Inj Sol [KMC]

Facility

$205.28

Service Code	HCPCS J3430
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$199.12
Rate for Payer: AlohaCare Medicaid	$102.64
Rate for Payer: AlohaCare Medicare	$86.22
Rate for Payer: Cash Price	$133.43
Rate for Payer: Cash Price	$133.43
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$188.86
Rate for Payer: Devoted Health Medicare	$86.22
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.84
Rate for Payer: Hawaii Medical Service Association Medicare	$86.22
Rate for Payer: Hawaii Western Management Group Commercial	$195.02
Rate for Payer: Health Management Network Commercial	$174.49
Rate for Payer: Humana Medicare	$86.22
Rate for Payer: Kaiser Permanente Commercial	$184.75
Rate for Payer: Kaiser Permanente Medicaid	$104.69
Rate for Payer: Kaiser Permanente Medicare	$86.22
Rate for Payer: MDX Hawaii PPO	$199.12
Rate for Payer: Ohana Health Plan Medicaid	$86.22
Rate for Payer: Ohana Health Plan Medicare	$86.22
Rate for Payer: UnitedHealthcare Medicaid	$123.17
Rate for Payer: UnitedHealthcare Medicare	$86.22
Rate for Payer: University Health Alliance Commercial	$149.63

phytonadione 10 mg/mL Inj Sol [KMC]

Facility

$205.28

Service Code	HCPCS J3430
Hospital Revenue Code	636
Min. Negotiated Rate	$174.49
Max. Negotiated Rate	$199.12
Rate for Payer: Cash Price	$133.43
Rate for Payer: Health Management Network Commercial	$174.49
Rate for Payer: Kaiser Permanente Commercial	$184.75
Rate for Payer: MDX Hawaii PPO	$199.12

Know your out-of-pocket cost for care.

All Charges