Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

PR MEDROXYPROGESTERONE ACETATE

Professional

Both

$5.00

Service Code	HCPCS J1050
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Hawaii Western Management Group Commercial	$0.48
Rate for Payer: Health Management Network Commercial	$4.25

probenecid 500 mg Tab [KMC]

Facility

$3.93

Service Code	NDC 00591534701
Hospital Revenue Code	250
Min. Negotiated Rate	$3.34
Max. Negotiated Rate	$3.81
Rate for Payer: Cash Price	$2.55
Rate for Payer: Health Management Network Commercial	$3.34
Rate for Payer: Kaiser Permanente Commercial	$3.54
Rate for Payer: MDX Hawaii PPO	$3.81

probenecid 500 mg Tab [KMC]

Facility

$3.93

Service Code	NDC 00591534701
Hospital Revenue Code	250
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$3.81
Rate for Payer: AlohaCare Medicaid	$1.97
Rate for Payer: AlohaCare Medicare	$1.65
Rate for Payer: Cash Price	$2.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.62
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.65
Rate for Payer: Hawaii Western Management Group Commercial	$3.73
Rate for Payer: Health Management Network Commercial	$3.34
Rate for Payer: Humana Medicare	$1.65
Rate for Payer: Kaiser Permanente Commercial	$3.54
Rate for Payer: Kaiser Permanente Medicaid	$2.00
Rate for Payer: Kaiser Permanente Medicare	$1.65
Rate for Payer: MDX Hawaii PPO	$3.81
Rate for Payer: Ohana Health Plan Medicaid	$1.65
Rate for Payer: Ohana Health Plan Medicare	$1.65
Rate for Payer: UnitedHealthcare Medicaid	$2.36
Rate for Payer: UnitedHealthcare Medicare	$1.65
Rate for Payer: University Health Alliance Commercial	$2.86

procainamide 1000 mg/10 mL Inj Sol [KMC]

Facility

$204.00

Service Code	HCPCS J2690
Hospital Revenue Code	636
Min. Negotiated Rate	$173.40
Max. Negotiated Rate	$197.88
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: MDX Hawaii PPO	$197.88

procainamide 1000 mg/10 mL Inj Sol [KMC]

Facility

$204.00

Service Code	HCPCS J2690
Hospital Revenue Code	636
Min. Negotiated Rate	$85.68
Max. Negotiated Rate	$268.51
Rate for Payer: AlohaCare Medicaid	$102.00
Rate for Payer: AlohaCare Medicare	$85.68
Rate for Payer: Cash Price	$132.60
Rate for Payer: Cash Price	$132.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$187.68
Rate for Payer: Devoted Health Medicare	$85.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$194.32
Rate for Payer: Hawaii Medical Service Association Commercial	$268.51
Rate for Payer: Hawaii Medical Service Association Medicare	$85.68
Rate for Payer: Hawaii Western Management Group Commercial	$193.80
Rate for Payer: Health Management Network Commercial	$173.40
Rate for Payer: Humana Medicare	$85.68
Rate for Payer: Kaiser Permanente Commercial	$183.60
Rate for Payer: Kaiser Permanente Medicaid	$104.04
Rate for Payer: Kaiser Permanente Medicare	$85.68
Rate for Payer: MDX Hawaii PPO	$197.88
Rate for Payer: Ohana Health Plan Medicaid	$85.68
Rate for Payer: Ohana Health Plan Medicare	$85.68
Rate for Payer: UnitedHealthcare Medicaid	$122.40
Rate for Payer: UnitedHealthcare Medicare	$85.68
Rate for Payer: University Health Alliance Commercial	$148.70

prochlorperazine 10 mg Tab

Facility

$3.57

Service Code	HCPCS Q0164
Hospital Revenue Code	637
Min. Negotiated Rate	$3.03
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$2.32
Rate for Payer: Health Management Network Commercial	$3.03
Rate for Payer: Kaiser Permanente Commercial	$3.21
Rate for Payer: MDX Hawaii PPO	$3.46

prochlorperazine 10 mg Tab

Facility

$3.57

Service Code	HCPCS Q0164
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.46
Rate for Payer: AlohaCare Medicaid	$1.78
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$2.32
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.28
Rate for Payer: Devoted Health Medicare	$1.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$3.39
Rate for Payer: Health Management Network Commercial	$3.03
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$3.21
Rate for Payer: Kaiser Permanente Medicaid	$1.82
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$3.46
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.60

prochlorperazine 5 mg/mL Sol [KMC]

Facility

$44.40

Service Code	HCPCS J0780
Hospital Revenue Code	636
Min. Negotiated Rate	$37.74
Max. Negotiated Rate	$43.07
Rate for Payer: Cash Price	$28.86
Rate for Payer: Health Management Network Commercial	$37.74
Rate for Payer: Kaiser Permanente Commercial	$39.96
Rate for Payer: MDX Hawaii PPO	$43.07

prochlorperazine 5 mg/mL Sol [KMC]

Facility

$44.40

Service Code	HCPCS J0780
Hospital Revenue Code	636
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$43.07
Rate for Payer: AlohaCare Medicaid	$22.20
Rate for Payer: AlohaCare Medicare	$18.65
Rate for Payer: Cash Price	$28.86
Rate for Payer: Cash Price	$28.86
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$40.85
Rate for Payer: Devoted Health Medicare	$18.65
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$18.65
Rate for Payer: Hawaii Western Management Group Commercial	$42.18
Rate for Payer: Health Management Network Commercial	$37.74
Rate for Payer: Humana Medicare	$18.65
Rate for Payer: Kaiser Permanente Commercial	$39.96
Rate for Payer: Kaiser Permanente Medicaid	$22.64
Rate for Payer: Kaiser Permanente Medicare	$18.65
Rate for Payer: MDX Hawaii PPO	$43.07
Rate for Payer: Ohana Health Plan Medicaid	$18.65
Rate for Payer: Ohana Health Plan Medicare	$18.65
Rate for Payer: UnitedHealthcare Medicaid	$26.64
Rate for Payer: UnitedHealthcare Medicare	$18.65
Rate for Payer: University Health Alliance Commercial	$32.36

PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 NJX

Professional

Both

$31.00

Service Code	HCPCS 95115
Hospital Revenue Code	636
Min. Negotiated Rate	$11.59
Max. Negotiated Rate	$26.35
Rate for Payer: AlohaCare Medicaid	$11.66
Rate for Payer: AlohaCare Medicare	$11.59
Rate for Payer: Cash Price	$20.15
Rate for Payer: Cash Price	$20.15
Rate for Payer: Devoted Health Medicare	$11.59
Rate for Payer: Hawaii Medical Service Association Medicare	$11.59
Rate for Payer: Hawaii Western Management Group Commercial	$16.36
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$13.91
Rate for Payer: Kaiser Permanente Medicaid	$13.91
Rate for Payer: Kaiser Permanente Medicare	$13.91
Rate for Payer: Ohana Health Plan Medicaid	$11.66
Rate for Payer: Ohana Health Plan Medicare	$11.59
Rate for Payer: UnitedHealthcare Medicaid	$11.66
Rate for Payer: UnitedHealthcare Medicare	$11.59

PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS

Professional

Both

$35.00

Service Code	HCPCS 95117
Hospital Revenue Code	636
Min. Negotiated Rate	$13.87
Max. Negotiated Rate	$29.75
Rate for Payer: AlohaCare Medicaid	$13.96
Rate for Payer: AlohaCare Medicare	$13.87
Rate for Payer: Cash Price	$22.75
Rate for Payer: Cash Price	$22.75
Rate for Payer: Devoted Health Medicare	$13.87
Rate for Payer: Hawaii Medical Service Association Medicare	$13.87
Rate for Payer: Hawaii Western Management Group Commercial	$17.23
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$16.64
Rate for Payer: Kaiser Permanente Medicaid	$16.64
Rate for Payer: Kaiser Permanente Medicare	$16.64
Rate for Payer: Ohana Health Plan Medicaid	$13.96
Rate for Payer: Ohana Health Plan Medicare	$13.87
Rate for Payer: UnitedHealthcare Medicaid	$13.96
Rate for Payer: UnitedHealthcare Medicare	$13.87

progesterone 100 mg Cap [KMC]

Facility

$8.52

Service Code	NDC 69543037410
Hospital Revenue Code	250
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$8.26
Rate for Payer: Cash Price	$5.54
Rate for Payer: Health Management Network Commercial	$7.24
Rate for Payer: Kaiser Permanente Commercial	$7.67
Rate for Payer: MDX Hawaii PPO	$8.26

progesterone 100 mg Cap [KMC]

Facility

$8.52

Service Code	NDC 69543037410
Hospital Revenue Code	250
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$8.26
Rate for Payer: AlohaCare Medicaid	$4.26
Rate for Payer: AlohaCare Medicare	$3.58
Rate for Payer: Cash Price	$5.54
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.84
Rate for Payer: Devoted Health Medicare	$3.58
Rate for Payer: Hawaii Medical Service Association Medicare	$3.58
Rate for Payer: Hawaii Western Management Group Commercial	$8.09
Rate for Payer: Health Management Network Commercial	$7.24
Rate for Payer: Humana Medicare	$3.58
Rate for Payer: Kaiser Permanente Commercial	$7.67
Rate for Payer: Kaiser Permanente Medicaid	$4.35
Rate for Payer: Kaiser Permanente Medicare	$3.58
Rate for Payer: MDX Hawaii PPO	$8.26
Rate for Payer: Ohana Health Plan Medicaid	$3.58
Rate for Payer: Ohana Health Plan Medicare	$3.58
Rate for Payer: UnitedHealthcare Medicaid	$5.11
Rate for Payer: UnitedHealthcare Medicare	$3.58
Rate for Payer: University Health Alliance Commercial	$6.21

Progesterone DLS

Facility

$182.00

Service Code	HCPCS 84144
Hospital Charge Code	422841445
Hospital Revenue Code	301
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$118.30
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: MDX Hawaii PPO	$176.54

Progesterone DLS

Facility

$182.00

Service Code	HCPCS 84144
Hospital Charge Code	422841445
Hospital Revenue Code	301
Min. Negotiated Rate	$20.86
Max. Negotiated Rate	$176.54
Rate for Payer: AlohaCare Medicaid	$91.00
Rate for Payer: AlohaCare Medicare	$76.44
Rate for Payer: Cash Price	$118.30
Rate for Payer: Cash Price	$118.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$167.44
Rate for Payer: Devoted Health Medicare	$76.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$28.83
Rate for Payer: Hawaii Medical Service Association Commercial	$26.07
Rate for Payer: Hawaii Medical Service Association Medicare	$76.44
Rate for Payer: Hawaii Western Management Group Commercial	$20.86
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Humana Medicare	$76.44
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: Kaiser Permanente Medicaid	$92.82
Rate for Payer: Kaiser Permanente Medicare	$76.44
Rate for Payer: MDX Hawaii PPO	$176.54
Rate for Payer: Ohana Health Plan Medicaid	$76.44
Rate for Payer: Ohana Health Plan Medicare	$76.44
Rate for Payer: UnitedHealthcare Medicaid	$28.83
Rate for Payer: UnitedHealthcare Medicare	$76.44
Rate for Payer: University Health Alliance Commercial	$53.93

Prolactin DLS

Facility

$205.00

Service Code	HCPCS 84146
Hospital Charge Code	422841465
Hospital Revenue Code	301
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

Prolactin DLS

Facility

$205.00

Service Code	HCPCS 84146
Hospital Charge Code	422841465
Hospital Revenue Code	301
Min. Negotiated Rate	$19.38
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$86.10
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$188.60
Rate for Payer: Devoted Health Medicare	$86.10
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$26.78
Rate for Payer: Hawaii Medical Service Association Commercial	$24.23
Rate for Payer: Hawaii Medical Service Association Medicare	$86.10
Rate for Payer: Hawaii Western Management Group Commercial	$19.38
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$86.10
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$86.10
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$86.10
Rate for Payer: Ohana Health Plan Medicare	$86.10
Rate for Payer: UnitedHealthcare Medicaid	$26.78
Rate for Payer: UnitedHealthcare Medicare	$86.10
Rate for Payer: University Health Alliance Commercial	$50.10

PROLOTHERAPY

Professional

Both

$100.00

Service Code	HCPCS M0076
Hospital Revenue Code	361
Min. Negotiated Rate	$85.00
Max. Negotiated Rate	$85.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Health Management Network Commercial	$85.00

promethazine 25 mg/mL Inj Sol [KMC]

Facility

$8.87

Service Code	HCPCS J2550
Hospital Revenue Code	636
Min. Negotiated Rate	$7.54
Max. Negotiated Rate	$8.60
Rate for Payer: Cash Price	$5.77
Rate for Payer: Health Management Network Commercial	$7.54
Rate for Payer: Kaiser Permanente Commercial	$7.98
Rate for Payer: MDX Hawaii PPO	$8.60

promethazine 25 mg/mL Inj Sol [KMC]

Facility

$8.87

Service Code	HCPCS J2550
Hospital Revenue Code	636
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$8.60
Rate for Payer: AlohaCare Medicaid	$4.43
Rate for Payer: AlohaCare Medicare	$3.73
Rate for Payer: Cash Price	$5.77
Rate for Payer: Cash Price	$5.77
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.16
Rate for Payer: Devoted Health Medicare	$3.73
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.87
Rate for Payer: Hawaii Medical Service Association Medicare	$3.73
Rate for Payer: Hawaii Western Management Group Commercial	$8.43
Rate for Payer: Health Management Network Commercial	$7.54
Rate for Payer: Humana Medicare	$3.73
Rate for Payer: Kaiser Permanente Commercial	$7.98
Rate for Payer: Kaiser Permanente Medicaid	$4.52
Rate for Payer: Kaiser Permanente Medicare	$3.73
Rate for Payer: MDX Hawaii PPO	$8.60
Rate for Payer: Ohana Health Plan Medicaid	$3.73
Rate for Payer: Ohana Health Plan Medicare	$3.73
Rate for Payer: UnitedHealthcare Medicaid	$5.32
Rate for Payer: UnitedHealthcare Medicare	$3.73
Rate for Payer: University Health Alliance Commercial	$6.47

promethazine 25 mg Sup [KMC]

Facility

$70.82

Service Code	NDC 00591299239
Hospital Revenue Code	250
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$68.70
Rate for Payer: Cash Price	$46.03
Rate for Payer: Health Management Network Commercial	$60.20
Rate for Payer: Kaiser Permanente Commercial	$63.74
Rate for Payer: MDX Hawaii PPO	$68.70

promethazine 25 mg Sup [KMC]

Facility

$70.82

Service Code	NDC 00591299239
Hospital Revenue Code	250
Min. Negotiated Rate	$29.74
Max. Negotiated Rate	$68.70
Rate for Payer: AlohaCare Medicaid	$35.41
Rate for Payer: AlohaCare Medicare	$29.74
Rate for Payer: Cash Price	$46.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$65.15
Rate for Payer: Devoted Health Medicare	$29.74
Rate for Payer: Hawaii Medical Service Association Medicare	$29.74
Rate for Payer: Hawaii Western Management Group Commercial	$67.28
Rate for Payer: Health Management Network Commercial	$60.20
Rate for Payer: Humana Medicare	$29.74
Rate for Payer: Kaiser Permanente Commercial	$63.74
Rate for Payer: Kaiser Permanente Medicaid	$36.12
Rate for Payer: Kaiser Permanente Medicare	$29.74
Rate for Payer: MDX Hawaii PPO	$68.70
Rate for Payer: Ohana Health Plan Medicaid	$29.74
Rate for Payer: Ohana Health Plan Medicare	$29.74
Rate for Payer: UnitedHealthcare Medicaid	$42.49
Rate for Payer: UnitedHealthcare Medicare	$29.74
Rate for Payer: University Health Alliance Commercial	$51.62

promethazine 25 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

promethazine 25 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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

propafenone 150 mg Tab [KMC]

Facility

$6.54

Service Code	NDC 00603544821
Hospital Revenue Code	250
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$6.34
Rate for Payer: AlohaCare Medicaid	$3.27
Rate for Payer: AlohaCare Medicare	$2.75
Rate for Payer: Cash Price	$4.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.02
Rate for Payer: Devoted Health Medicare	$2.75
Rate for Payer: Hawaii Medical Service Association Medicare	$2.75
Rate for Payer: Hawaii Western Management Group Commercial	$6.21
Rate for Payer: Health Management Network Commercial	$5.56
Rate for Payer: Humana Medicare	$2.75
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: Kaiser Permanente Medicaid	$3.34
Rate for Payer: Kaiser Permanente Medicare	$2.75
Rate for Payer: MDX Hawaii PPO	$6.34
Rate for Payer: Ohana Health Plan Medicaid	$2.75
Rate for Payer: Ohana Health Plan Medicare	$2.75
Rate for Payer: UnitedHealthcare Medicaid	$3.92
Rate for Payer: UnitedHealthcare Medicare	$2.75
Rate for Payer: University Health Alliance Commercial	$4.77

Know your out-of-pocket cost for care.

All Charges