Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Potassium Level

Facility

$72.00

Service Code	HCPCS 84132
Hospital Charge Code	422841320
Hospital Revenue Code	301
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$30.24
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$66.24
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.35
Rate for Payer: Hawaii Medical Service Association Commercial	$5.95
Rate for Payer: Hawaii Medical Service Association Medicare	$30.24
Rate for Payer: Hawaii Western Management Group Commercial	$4.76
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$30.24
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$30.24
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$30.24
Rate for Payer: Ohana Health Plan Medicare	$30.24
Rate for Payer: UnitedHealthcare Medicaid	$6.35
Rate for Payer: UnitedHealthcare Medicare	$30.24
Rate for Payer: University Health Alliance Commercial	$11.88

Potassium Level

Facility

$72.00

Service Code	HCPCS 84132
Hospital Charge Code	422841320
Hospital Revenue Code	301
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84

potassium phosphate 45 mmol / 15 mL (w/ K 66 mEq / 15 mL) Soln [KMC]

Facility

$14.40

Service Code	NDC 80830169102
Hospital Revenue Code	250
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$13.97
Rate for Payer: AlohaCare Medicaid	$7.20
Rate for Payer: AlohaCare Medicare	$6.05
Rate for Payer: Cash Price	$9.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.25
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$6.05
Rate for Payer: Hawaii Western Management Group Commercial	$13.68
Rate for Payer: Health Management Network Commercial	$12.24
Rate for Payer: Humana Medicare	$6.05
Rate for Payer: Kaiser Permanente Commercial	$12.96
Rate for Payer: Kaiser Permanente Medicaid	$7.34
Rate for Payer: Kaiser Permanente Medicare	$6.05
Rate for Payer: MDX Hawaii PPO	$13.97
Rate for Payer: Ohana Health Plan Medicaid	$6.05
Rate for Payer: Ohana Health Plan Medicare	$6.05
Rate for Payer: UnitedHealthcare Medicaid	$8.64
Rate for Payer: UnitedHealthcare Medicare	$6.05
Rate for Payer: University Health Alliance Commercial	$10.50

potassium phosphate 45 mmol / 15 mL (w/ K 66 mEq / 15 mL) Soln [KMC]

Facility

$14.40

Service Code	NDC 80830169102
Hospital Revenue Code	250
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$13.97
Rate for Payer: Cash Price	$9.36
Rate for Payer: Health Management Network Commercial	$12.24
Rate for Payer: Kaiser Permanente Commercial	$12.96
Rate for Payer: MDX Hawaii PPO	$13.97

POVIDINE-IODINE SWABSTICKS 4" SATURATED

Facility

$244.00

Hospital Charge Code	8574
Hospital Revenue Code	270
Min. Negotiated Rate	$207.40
Max. Negotiated Rate	$236.68
Rate for Payer: Cash Price	$158.60
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$219.60
Rate for Payer: MDX Hawaii PPO	$236.68

POVIDINE-IODINE SWABSTICKS 4" SATURATED

Facility

$244.00

Hospital Charge Code	8574
Hospital Revenue Code	270
Min. Negotiated Rate	$102.48
Max. Negotiated Rate	$236.68
Rate for Payer: AlohaCare Medicaid	$122.00
Rate for Payer: AlohaCare Medicare	$102.48
Rate for Payer: Cash Price	$158.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$224.48
Rate for Payer: Devoted Health Medicare	$102.48
Rate for Payer: Hawaii Medical Service Association Medicare	$102.48
Rate for Payer: Hawaii Western Management Group Commercial	$231.80
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Humana Medicare	$102.48
Rate for Payer: Kaiser Permanente Commercial	$219.60
Rate for Payer: Kaiser Permanente Medicaid	$124.44
Rate for Payer: Kaiser Permanente Medicare	$102.48
Rate for Payer: MDX Hawaii PPO	$236.68
Rate for Payer: Ohana Health Plan Medicaid	$102.48
Rate for Payer: Ohana Health Plan Medicare	$102.48
Rate for Payer: UnitedHealthcare Medicare	$102.48
Rate for Payer: University Health Alliance Commercial	$177.85

povidone iodine Top 10% Soln [KMC]

Facility

$0.06

Service Code	NDC 67618015004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.06
Rate for Payer: AlohaCare Medicaid	$0.03
Rate for Payer: AlohaCare Medicare	$0.03
Rate for Payer: Cash Price	$0.04
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.06
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Hawaii Medical Service Association Medicare	$0.03
Rate for Payer: Hawaii Western Management Group Commercial	$0.06
Rate for Payer: Health Management Network Commercial	$0.05
Rate for Payer: Humana Medicare	$0.03
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: Kaiser Permanente Medicaid	$0.03
Rate for Payer: Kaiser Permanente Medicare	$0.03
Rate for Payer: MDX Hawaii PPO	$0.06
Rate for Payer: Ohana Health Plan Medicaid	$0.03
Rate for Payer: Ohana Health Plan Medicare	$0.03
Rate for Payer: UnitedHealthcare Medicaid	$0.04
Rate for Payer: UnitedHealthcare Medicare	$0.03
Rate for Payer: University Health Alliance Commercial	$0.04

povidone iodine Top 10% Soln [KMC]

Facility

$0.06

Service Code	NDC 67618015004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Management Network Commercial	$0.05
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: MDX Hawaii PPO	$0.06

PPPS, INITIAL VISIT

Professional

Both

$494.00

Service Code	HCPCS G0438
Hospital Revenue Code	521
Min. Negotiated Rate	$152.00
Max. Negotiated Rate	$419.90
Rate for Payer: AlohaCare Medicaid	$173.87
Rate for Payer: AlohaCare Medicare	$183.17
Rate for Payer: Cash Price	$321.10
Rate for Payer: Cash Price	$321.10
Rate for Payer: Cash Price	$321.10
Rate for Payer: Devoted Health Medicare	$183.17
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: Hawaii Western Management Group Commercial	$181.50
Rate for Payer: Health Management Network Commercial	$419.90
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$219.80
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: Ohana Health Plan Medicaid	$173.87
Rate for Payer: Ohana Health Plan Medicare	$183.17
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PPPS, SUBSEQ VISIT

Professional

Both

$337.00

Service Code	HCPCS G0439
Hospital Revenue Code	521
Min. Negotiated Rate	$122.58
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$137.48
Rate for Payer: AlohaCare Medicare	$145.26
Rate for Payer: Cash Price	$219.05
Rate for Payer: Cash Price	$219.05
Rate for Payer: Cash Price	$219.05
Rate for Payer: Devoted Health Medicare	$145.26
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: Hawaii Western Management Group Commercial	$122.58
Rate for Payer: Health Management Network Commercial	$286.45
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$174.31
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: Ohana Health Plan Medicaid	$137.48
Rate for Payer: Ohana Health Plan Medicare	$145.26
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

PPSV23 VACCINE 2 YRS OR OLDER FOR SUBQ/IM USE

Professional

Both

$219.00

Service Code	HCPCS 90732
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$186.15
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$133.47
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Devoted Health Medicare	$133.47
Rate for Payer: Hawaii Medical Service Association Medicare	$133.47
Rate for Payer: Hawaii Western Management Group Commercial	$95.45
Rate for Payer: Health Management Network Commercial	$186.15
Rate for Payer: Kaiser Permanente Commercial	$160.16
Rate for Payer: Kaiser Permanente Medicaid	$160.16
Rate for Payer: Kaiser Permanente Medicare	$160.16
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$133.47
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$133.47

PPSV23 VACCINE 2 YRS OR OLDER FOR SUBQ/IM USE

Professional

Both

$0.01

Service Code	HCPCS 90732 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$95.45
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$95.45
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

PR ALBUTEROL NON-COMP UNIT

Professional

Both

$4.00

Service Code	HCPCS J7613
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$3.40
Rate for Payer: AlohaCare Medicare	$0.08
Rate for Payer: Cash Price	$2.60
Rate for Payer: Cash Price	$2.60
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Hawaii Medical Service Association Medicare	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$2.34
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$0.10
Rate for Payer: Kaiser Permanente Medicaid	$0.10
Rate for Payer: Kaiser Permanente Medicare	$0.10
Rate for Payer: Ohana Health Plan Medicare	$0.08
Rate for Payer: UnitedHealthcare Medicare	$0.08

pramipexole 0.125 mg Tab [KMC]

Facility

$11.80

Service Code	NDC 57237018090
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$11.45
Rate for Payer: AlohaCare Medicaid	$5.90
Rate for Payer: AlohaCare Medicare	$4.96
Rate for Payer: Cash Price	$7.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.86
Rate for Payer: Devoted Health Medicare	$4.96
Rate for Payer: Hawaii Medical Service Association Medicare	$4.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.21
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Humana Medicare	$4.96
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: Kaiser Permanente Medicaid	$6.02
Rate for Payer: Kaiser Permanente Medicare	$4.96
Rate for Payer: MDX Hawaii PPO	$11.45
Rate for Payer: Ohana Health Plan Medicaid	$4.96
Rate for Payer: Ohana Health Plan Medicare	$4.96
Rate for Payer: UnitedHealthcare Medicaid	$7.08
Rate for Payer: UnitedHealthcare Medicare	$4.96
Rate for Payer: University Health Alliance Commercial	$8.60

pramipexole 0.125 mg Tab [KMC]

Facility

$11.80

Service Code	NDC 57237018090
Hospital Revenue Code	250
Min. Negotiated Rate	$10.03
Max. Negotiated Rate	$11.45
Rate for Payer: Cash Price	$7.67
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: MDX Hawaii PPO	$11.45

pramipexole 0.250 mg tablet [KMC]

Facility

$11.80

Service Code	NDC 57237018190
Hospital Revenue Code	250
Min. Negotiated Rate	$10.03
Max. Negotiated Rate	$11.45
Rate for Payer: Cash Price	$7.67
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: MDX Hawaii PPO	$11.45

pramipexole 0.250 mg tablet [KMC]

Facility

$11.80

Service Code	NDC 57237018190
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$11.45
Rate for Payer: AlohaCare Medicaid	$5.90
Rate for Payer: AlohaCare Medicare	$4.96
Rate for Payer: Cash Price	$7.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.86
Rate for Payer: Devoted Health Medicare	$4.96
Rate for Payer: Hawaii Medical Service Association Medicare	$4.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.21
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Humana Medicare	$4.96
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: Kaiser Permanente Medicaid	$6.02
Rate for Payer: Kaiser Permanente Medicare	$4.96
Rate for Payer: MDX Hawaii PPO	$11.45
Rate for Payer: Ohana Health Plan Medicaid	$4.96
Rate for Payer: Ohana Health Plan Medicare	$4.96
Rate for Payer: UnitedHealthcare Medicaid	$7.08
Rate for Payer: UnitedHealthcare Medicare	$4.96
Rate for Payer: University Health Alliance Commercial	$8.60

pramipexole 1.5 mg Tab [KMC]

Facility

$11.80

Service Code	NDC 57237018590
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$11.45
Rate for Payer: AlohaCare Medicaid	$5.90
Rate for Payer: AlohaCare Medicare	$4.96
Rate for Payer: Cash Price	$7.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.86
Rate for Payer: Devoted Health Medicare	$4.96
Rate for Payer: Hawaii Medical Service Association Medicare	$4.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.21
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Humana Medicare	$4.96
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: Kaiser Permanente Medicaid	$6.02
Rate for Payer: Kaiser Permanente Medicare	$4.96
Rate for Payer: MDX Hawaii PPO	$11.45
Rate for Payer: Ohana Health Plan Medicaid	$4.96
Rate for Payer: Ohana Health Plan Medicare	$4.96
Rate for Payer: UnitedHealthcare Medicaid	$7.08
Rate for Payer: UnitedHealthcare Medicare	$4.96
Rate for Payer: University Health Alliance Commercial	$8.60

pramipexole 1.5 mg Tab [KMC]

Facility

$11.80

Service Code	NDC 57237018590
Hospital Revenue Code	250
Min. Negotiated Rate	$10.03
Max. Negotiated Rate	$11.45
Rate for Payer: Cash Price	$7.67
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: MDX Hawaii PPO	$11.45

pramipexole 1 mg Tab [KMC]

Facility

$11.80

Service Code	NDC 57237018490
Hospital Revenue Code	250
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$11.45
Rate for Payer: AlohaCare Medicaid	$5.90
Rate for Payer: AlohaCare Medicare	$4.96
Rate for Payer: Cash Price	$7.67
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.86
Rate for Payer: Devoted Health Medicare	$4.96
Rate for Payer: Hawaii Medical Service Association Medicare	$4.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.21
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Humana Medicare	$4.96
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: Kaiser Permanente Medicaid	$6.02
Rate for Payer: Kaiser Permanente Medicare	$4.96
Rate for Payer: MDX Hawaii PPO	$11.45
Rate for Payer: Ohana Health Plan Medicaid	$4.96
Rate for Payer: Ohana Health Plan Medicare	$4.96
Rate for Payer: UnitedHealthcare Medicaid	$7.08
Rate for Payer: UnitedHealthcare Medicare	$4.96
Rate for Payer: University Health Alliance Commercial	$8.60

pramipexole 1 mg Tab [KMC]

Facility

$11.80

Service Code	NDC 57237018490
Hospital Revenue Code	250
Min. Negotiated Rate	$10.03
Max. Negotiated Rate	$11.45
Rate for Payer: Cash Price	$7.67
Rate for Payer: Health Management Network Commercial	$10.03
Rate for Payer: Kaiser Permanente Commercial	$10.62
Rate for Payer: MDX Hawaii PPO	$11.45

pramoxine Top 1% Lotion [KMC]

Facility

$0.13

Service Code	NDC 00145063005
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.13
Rate for Payer: AlohaCare Medicaid	$0.07
Rate for Payer: AlohaCare Medicare	$0.05
Rate for Payer: Cash Price	$0.08
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.12
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Hawaii Medical Service Association Medicare	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$0.12
Rate for Payer: Health Management Network Commercial	$0.11
Rate for Payer: Humana Medicare	$0.05
Rate for Payer: Kaiser Permanente Commercial	$0.12
Rate for Payer: Kaiser Permanente Medicaid	$0.07
Rate for Payer: Kaiser Permanente Medicare	$0.05
Rate for Payer: MDX Hawaii PPO	$0.13
Rate for Payer: Ohana Health Plan Medicaid	$0.05
Rate for Payer: Ohana Health Plan Medicare	$0.05
Rate for Payer: UnitedHealthcare Medicaid	$0.08
Rate for Payer: UnitedHealthcare Medicare	$0.05
Rate for Payer: University Health Alliance Commercial	$0.09

pramoxine Top 1% Lotion [KMC]

Facility

$0.13

Service Code	NDC 00145063005
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Management Network Commercial	$0.11
Rate for Payer: Kaiser Permanente Commercial	$0.12
Rate for Payer: MDX Hawaii PPO	$0.13

pramoxine-zinc 1% Lotion [KMC]

Facility

$0.10

Service Code	NDC 49348061036
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: AlohaCare Medicaid	$0.05
Rate for Payer: AlohaCare Medicare	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$0.10
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.10
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.06
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

pramoxine-zinc 1% Lotion [KMC]

Facility

$0.10

Service Code	NDC 49348061036
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.09
Rate for Payer: Kaiser Permanente Commercial	$0.09
Rate for Payer: MDX Hawaii PPO	$0.10

Know your out-of-pocket cost for care.

All Charges