Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Pre-Pack - azithromycin 200 mg/5 mL REC Susp [KMC]

Facility

$4.65

Service Code	HCPCS Q0144
Hospital Revenue Code	637
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$4.51
Rate for Payer: AlohaCare Medicaid	$2.33
Rate for Payer: AlohaCare Medicare	$1.95
Rate for Payer: Cash Price	$3.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.28
Rate for Payer: Devoted Health Medicare	$1.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1.95
Rate for Payer: Hawaii Western Management Group Commercial	$4.42
Rate for Payer: Health Management Network Commercial	$3.95
Rate for Payer: Humana Medicare	$1.95
Rate for Payer: Kaiser Permanente Commercial	$4.18
Rate for Payer: Kaiser Permanente Medicaid	$2.37
Rate for Payer: Kaiser Permanente Medicare	$1.95
Rate for Payer: MDX Hawaii PPO	$4.51
Rate for Payer: Ohana Health Plan Medicaid	$1.95
Rate for Payer: Ohana Health Plan Medicare	$1.95
Rate for Payer: UnitedHealthcare Medicare	$1.95
Rate for Payer: University Health Alliance Commercial	$3.39

Pre-Pack - cephalexin 250 mg/5 mL REC Susp [KMC]

Facility

$1.15

Service Code	NDC 00093417773
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.75
Rate for Payer: Health Management Network Commercial	$0.98
Rate for Payer: Kaiser Permanente Commercial	$1.03
Rate for Payer: MDX Hawaii PPO	$1.12

Pre-Pack - cephalexin 250 mg/5 mL REC Susp [KMC]

Facility

$1.15

Service Code	NDC 00093417773
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.12
Rate for Payer: AlohaCare Medicaid	$0.58
Rate for Payer: AlohaCare Medicare	$0.48
Rate for Payer: Cash Price	$0.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.06
Rate for Payer: Devoted Health Medicare	$0.48
Rate for Payer: Hawaii Medical Service Association Medicare	$0.48
Rate for Payer: Hawaii Western Management Group Commercial	$1.09
Rate for Payer: Health Management Network Commercial	$0.98
Rate for Payer: Humana Medicare	$0.48
Rate for Payer: Kaiser Permanente Commercial	$1.03
Rate for Payer: Kaiser Permanente Medicaid	$0.59
Rate for Payer: Kaiser Permanente Medicare	$0.48
Rate for Payer: MDX Hawaii PPO	$1.12
Rate for Payer: Ohana Health Plan Medicaid	$0.48
Rate for Payer: Ohana Health Plan Medicare	$0.48
Rate for Payer: UnitedHealthcare Medicaid	$0.69
Rate for Payer: UnitedHealthcare Medicare	$0.48
Rate for Payer: University Health Alliance Commercial	$0.84

Preservision AREDS2 capsule [KMC]

Facility

$3.00

Service Code	NDC 24208069762
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

Preservision AREDS2 capsule [KMC]

Facility

$3.00

Service Code	NDC 24208069762
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

PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT

Professional

Both

$62.00

Service Code	HCPCS 94640
Hospital Revenue Code	410
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$52.70
Rate for Payer: AlohaCare Medicaid	$8.98
Rate for Payer: AlohaCare Medicare	$9.69
Rate for Payer: Cash Price	$40.30
Rate for Payer: Cash Price	$40.30
Rate for Payer: Devoted Health Medicare	$9.69
Rate for Payer: Hawaii Medical Service Association Medicare	$9.69
Rate for Payer: Hawaii Western Management Group Commercial	$17.23
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$11.63
Rate for Payer: Kaiser Permanente Medicaid	$11.63
Rate for Payer: Kaiser Permanente Medicare	$11.63
Rate for Payer: Ohana Health Plan Medicaid	$8.98
Rate for Payer: Ohana Health Plan Medicare	$9.69
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$9.69

PREVALON AIRTAP

Facility

$2.00

Hospital Charge Code	8556
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

PREVALON AIRTAP

Facility

$2.00

Hospital Charge Code	8556
Hospital Revenue Code	270
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 15 MIN

Professional

Both

$373.00

Service Code	HCPCS 99401
Hospital Revenue Code	521
Min. Negotiated Rate	$21.55
Max. Negotiated Rate	$317.05
Rate for Payer: Cash Price	$242.45
Rate for Payer: Cash Price	$242.45
Rate for Payer: Cash Price	$242.45
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$21.55
Rate for Payer: Health Management Network Commercial	$317.05
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

PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 45 MIN

Professional

Both

$273.00

Service Code	HCPCS 99403
Hospital Revenue Code	521
Min. Negotiated Rate	$38.78
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
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	$38.78
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
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	$273.13
Rate for Payer: UnitedHealthcare Medicare	$152.00

PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 60 MIN

Professional

Both

$362.00

Service Code	HCPCS 99404
Hospital Revenue Code	521
Min. Negotiated Rate	$43.71
Max. Negotiated Rate	$307.70
Rate for Payer: Cash Price	$235.30
Rate for Payer: Cash Price	$235.30
Rate for Payer: Cash Price	$235.30
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Western Management Group Commercial	$43.71
Rate for Payer: Health Management Network Commercial	$307.70
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
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

Prevnar 13 (pneumococcal 13-valent conjugate vaccine)

Facility

$2,172.54

Service Code	NDC 00005197102
Hospital Revenue Code	250
Min. Negotiated Rate	$912.47
Max. Negotiated Rate	$2,107.36
Rate for Payer: AlohaCare Medicaid	$1,086.27
Rate for Payer: AlohaCare Medicare	$912.47
Rate for Payer: Cash Price	$1,412.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,998.74
Rate for Payer: Devoted Health Medicare	$912.47
Rate for Payer: Hawaii Medical Service Association Medicare	$912.47
Rate for Payer: Hawaii Western Management Group Commercial	$2,063.91
Rate for Payer: Health Management Network Commercial	$1,846.66
Rate for Payer: Humana Medicare	$912.47
Rate for Payer: Kaiser Permanente Commercial	$1,955.29
Rate for Payer: Kaiser Permanente Medicaid	$1,108.00
Rate for Payer: Kaiser Permanente Medicare	$912.47
Rate for Payer: MDX Hawaii PPO	$2,107.36
Rate for Payer: Ohana Health Plan Medicaid	$912.47
Rate for Payer: Ohana Health Plan Medicare	$912.47
Rate for Payer: UnitedHealthcare Medicaid	$1,303.52
Rate for Payer: UnitedHealthcare Medicare	$912.47
Rate for Payer: University Health Alliance Commercial	$1,583.56

Prevnar 13 (pneumococcal 13-valent conjugate vaccine)

Facility

$2,172.54

Service Code	NDC 00005197102
Hospital Revenue Code	250
Min. Negotiated Rate	$1,846.66
Max. Negotiated Rate	$2,107.36
Rate for Payer: Cash Price	$1,412.15
Rate for Payer: Health Management Network Commercial	$1,846.66
Rate for Payer: Kaiser Permanente Commercial	$1,955.29
Rate for Payer: MDX Hawaii PPO	$2,107.36

PRIMAFIT EXTERNAL URINE MANAGEMENT FEMALE

Facility

$69.00

Hospital Charge Code	8558
Hospital Revenue Code	270
Min. Negotiated Rate	$28.98
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: Deseret Mutual Benefit Administrators Commercial	$63.48
Rate for Payer: Devoted Health Medicare	$28.98
Rate for Payer: Hawaii Medical Service Association Medicare	$28.98
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
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 Medicare	$28.98
Rate for Payer: University Health Alliance Commercial	$50.29

PRIMAFIT EXTERNAL URINE MANAGEMENT FEMALE

Facility

$69.00

Hospital Charge Code	8558
Hospital Revenue Code	270
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

primaquine 26.3 mg Tab [KMC]

Facility

$8.09

Service Code	NDC 00024159601
Hospital Revenue Code	250
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$7.85
Rate for Payer: Cash Price	$5.26
Rate for Payer: Health Management Network Commercial	$6.88
Rate for Payer: Kaiser Permanente Commercial	$7.28
Rate for Payer: MDX Hawaii PPO	$7.85

primaquine 26.3 mg Tab [KMC]

Facility

$8.09

Service Code	NDC 00024159601
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$7.85
Rate for Payer: AlohaCare Medicaid	$4.04
Rate for Payer: AlohaCare Medicare	$3.40
Rate for Payer: Cash Price	$5.26
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.44
Rate for Payer: Devoted Health Medicare	$3.40
Rate for Payer: Hawaii Medical Service Association Medicare	$3.40
Rate for Payer: Hawaii Western Management Group Commercial	$7.69
Rate for Payer: Health Management Network Commercial	$6.88
Rate for Payer: Humana Medicare	$3.40
Rate for Payer: Kaiser Permanente Commercial	$7.28
Rate for Payer: Kaiser Permanente Medicaid	$4.13
Rate for Payer: Kaiser Permanente Medicare	$3.40
Rate for Payer: MDX Hawaii PPO	$7.85
Rate for Payer: Ohana Health Plan Medicaid	$3.40
Rate for Payer: Ohana Health Plan Medicare	$3.40
Rate for Payer: UnitedHealthcare Medicaid	$4.85
Rate for Payer: UnitedHealthcare Medicare	$3.40
Rate for Payer: University Health Alliance Commercial	$5.90

primidone 250 mg Tab [KMC]

Facility

$3.98

Service Code	NDC 53746054501
Hospital Revenue Code	250
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$3.86
Rate for Payer: AlohaCare Medicaid	$1.99
Rate for Payer: AlohaCare Medicare	$1.67
Rate for Payer: Cash Price	$2.59
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.66
Rate for Payer: Devoted Health Medicare	$1.67
Rate for Payer: Hawaii Medical Service Association Medicare	$1.67
Rate for Payer: Hawaii Western Management Group Commercial	$3.78
Rate for Payer: Health Management Network Commercial	$3.38
Rate for Payer: Humana Medicare	$1.67
Rate for Payer: Kaiser Permanente Commercial	$3.58
Rate for Payer: Kaiser Permanente Medicaid	$2.03
Rate for Payer: Kaiser Permanente Medicare	$1.67
Rate for Payer: MDX Hawaii PPO	$3.86
Rate for Payer: Ohana Health Plan Medicaid	$1.67
Rate for Payer: Ohana Health Plan Medicare	$1.67
Rate for Payer: UnitedHealthcare Medicaid	$2.39
Rate for Payer: UnitedHealthcare Medicare	$1.67
Rate for Payer: University Health Alliance Commercial	$2.90

primidone 250 mg Tab [KMC]

Facility

$3.98

Service Code	NDC 53746054501
Hospital Revenue Code	250
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$3.86
Rate for Payer: Cash Price	$2.59
Rate for Payer: Health Management Network Commercial	$3.38
Rate for Payer: Kaiser Permanente Commercial	$3.58
Rate for Payer: MDX Hawaii PPO	$3.86

primidone 50 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904555960
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

primidone 50 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904555960
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

PRIMOFIT EXTERNAL URINE MANAGEMENT MALE

Facility

$2.00

Hospital Charge Code	8557
Hospital Revenue Code	270
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.84
Rate for Payer: Cash Price	$1.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.84
Rate for Payer: Devoted Health Medicare	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.84
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.84
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.84
Rate for Payer: Ohana Health Plan Medicare	$0.84
Rate for Payer: UnitedHealthcare Medicare	$0.84
Rate for Payer: University Health Alliance Commercial	$1.46

PRIMOFIT EXTERNAL URINE MANAGEMENT MALE

Facility

$2.00

Hospital Charge Code	8557
Hospital Revenue Code	270
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: MDX Hawaii PPO	$1.94

PRISMA AG

Facility

$648.00

Hospital Charge Code	8496
Hospital Revenue Code	270
Min. Negotiated Rate	$550.80
Max. Negotiated Rate	$628.56
Rate for Payer: Cash Price	$421.20
Rate for Payer: Health Management Network Commercial	$550.80
Rate for Payer: Kaiser Permanente Commercial	$583.20
Rate for Payer: MDX Hawaii PPO	$628.56

PRISMA AG

Facility

$648.00

Hospital Charge Code	8496
Hospital Revenue Code	270
Min. Negotiated Rate	$272.16
Max. Negotiated Rate	$628.56
Rate for Payer: AlohaCare Medicaid	$324.00
Rate for Payer: AlohaCare Medicare	$272.16
Rate for Payer: Cash Price	$421.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$596.16
Rate for Payer: Devoted Health Medicare	$272.16
Rate for Payer: Hawaii Medical Service Association Medicare	$272.16
Rate for Payer: Hawaii Western Management Group Commercial	$615.60
Rate for Payer: Health Management Network Commercial	$550.80
Rate for Payer: Humana Medicare	$272.16
Rate for Payer: Kaiser Permanente Commercial	$583.20
Rate for Payer: Kaiser Permanente Medicaid	$330.48
Rate for Payer: Kaiser Permanente Medicare	$272.16
Rate for Payer: MDX Hawaii PPO	$628.56
Rate for Payer: Ohana Health Plan Medicaid	$272.16
Rate for Payer: Ohana Health Plan Medicare	$272.16
Rate for Payer: UnitedHealthcare Medicare	$272.16
Rate for Payer: University Health Alliance Commercial	$472.33

Know your out-of-pocket cost for care.

All Charges