Kau Hospital

All Charges

Charge

Type

Setting

Price

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$40.00

Service Code	NDC 31722004031
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: MDX Hawaii PPO	$38.80

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$45.00

Service Code	NDC 00713053612
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$45.00

Service Code	NDC 00713053612
Hospital Revenue Code	637
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$13.95
Rate for Payer: Cash Price	$27.00
Rate for Payer: Devoted Health Medicare	$15.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.95
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$13.95
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$13.95
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$13.95
Rate for Payer: Ohana Health Plan Medicare	$13.95
Rate for Payer: UnitedHealthcare Medicare	$13.95
Rate for Payer: University Health Alliance Commercial	$32.80

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

$40.00

Service Code	NDC 31722004031
Hospital Revenue Code	637
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$38.80
Rate for Payer: AlohaCare Medicaid	$20.00
Rate for Payer: AlohaCare Medicare	$12.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Devoted Health Medicare	$13.60
Rate for Payer: Hawaii Medical Service Association Medicare	$12.40
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Humana Medicare	$12.40
Rate for Payer: Kaiser Permanente Commercial	$36.00
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: Kaiser Permanente Medicare	$12.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: Ohana Health Plan Medicaid	$12.40
Rate for Payer: Ohana Health Plan Medicare	$12.40
Rate for Payer: UnitedHealthcare Medicare	$12.40
Rate for Payer: University Health Alliance Commercial	$29.16

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$2.00

Service Code	HCPCS Q0169
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
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

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

$2.00

Service Code	HCPCS Q0169
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

$8.00

Service Code	HCPCS J2550
Hospital Revenue Code	636
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$2.48
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$2.72
Rate for Payer: Hawaii Medical Service Association ABD	$2.87
Rate for Payer: Hawaii Medical Service Association Medicare	$2.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.87
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$2.48
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$2.48
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$2.48
Rate for Payer: Ohana Health Plan Medicare	$2.48
Rate for Payer: UnitedHealthcare Medicaid	$4.80
Rate for Payer: UnitedHealthcare Medicare	$2.48
Rate for Payer: University Health Alliance Commercial	$5.83

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

$8.00

Service Code	HCPCS J2550
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052606
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052612
Hospital Revenue Code	250
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052606
Hospital Revenue Code	637
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$13.95
Rate for Payer: Cash Price	$27.00
Rate for Payer: Devoted Health Medicare	$15.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.95
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$13.95
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$13.95
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$13.95
Rate for Payer: Ohana Health Plan Medicare	$13.95
Rate for Payer: UnitedHealthcare Medicare	$13.95
Rate for Payer: University Health Alliance Commercial	$32.80

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

$45.00

Service Code	NDC 00713052612
Hospital Revenue Code	637
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$43.65
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$13.95
Rate for Payer: Cash Price	$27.00
Rate for Payer: Devoted Health Medicare	$15.30
Rate for Payer: Hawaii Medical Service Association Medicare	$13.95
Rate for Payer: Hawaii Western Management Group Commercial	$42.75
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$13.95
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$13.95
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$13.95
Rate for Payer: Ohana Health Plan Medicare	$13.95
Rate for Payer: UnitedHealthcare Medicare	$13.95
Rate for Payer: University Health Alliance Commercial	$32.80

PROMETHAZINE 25 MG TABLET [6622]

Facility

$2.00

Service Code	HCPCS Q0169
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.94
Rate for Payer: AlohaCare Medicaid	$1.00
Rate for Payer: AlohaCare Medicare	$0.62
Rate for Payer: Cash Price	$1.20
Rate for Payer: Devoted Health Medicare	$0.68
Rate for Payer: Hawaii Medical Service Association Medicare	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Humana Medicare	$0.62
Rate for Payer: Kaiser Permanente Commercial	$1.80
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: Kaiser Permanente Medicare	$0.62
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: Ohana Health Plan Medicaid	$0.62
Rate for Payer: Ohana Health Plan Medicare	$0.62
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: UnitedHealthcare Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

PROMETHAZINE 25 MG TABLET [6622]

Facility

$2.00

Service Code	HCPCS Q0169
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
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

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$119.00

Service Code	NDC 27808005102
Hospital Revenue Code	250
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$71.40
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: MDX Hawaii PPO	$115.43

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$114.00

Service Code	NDC 00116402316
Hospital Revenue Code	637
Min. Negotiated Rate	$35.34
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$35.34
Rate for Payer: Cash Price	$68.40
Rate for Payer: Devoted Health Medicare	$38.76
Rate for Payer: Hawaii Medical Service Association Medicare	$35.34
Rate for Payer: Hawaii Western Management Group Commercial	$108.30
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$35.34
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$35.34
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$35.34
Rate for Payer: Ohana Health Plan Medicare	$35.34
Rate for Payer: UnitedHealthcare Medicare	$35.34
Rate for Payer: University Health Alliance Commercial	$83.09

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$114.00

Service Code	NDC 00116402316
Hospital Revenue Code	250
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$68.40
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP [97609]

Facility

$119.00

Service Code	NDC 27808005102
Hospital Revenue Code	637
Min. Negotiated Rate	$36.89
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$59.50
Rate for Payer: AlohaCare Medicare	$36.89
Rate for Payer: Cash Price	$71.40
Rate for Payer: Devoted Health Medicare	$40.46
Rate for Payer: Hawaii Medical Service Association Medicare	$36.89
Rate for Payer: Hawaii Western Management Group Commercial	$113.05
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$36.89
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$36.89
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$36.89
Rate for Payer: Ohana Health Plan Medicare	$36.89
Rate for Payer: UnitedHealthcare Medicare	$36.89
Rate for Payer: University Health Alliance Commercial	$86.74

PROMETHAZINE SUPPOSITORIES (PHENERGAN) 25 MG (TAKE HOME) [4080393]

Facility

$15.00

Service Code	NDC 00004080181
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

PROMETHAZINE SUPPOSITORIES (PHENERGAN) 25 MG (TAKE HOME) [4080393]

Facility

$15.00

Service Code	NDC 00004080181
Hospital Revenue Code	253
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

PROMETHAZINE TABLETS (PHENERGAN) 25 MG (TAKE HOME) [4080392]

Facility

$15.00

Service Code	HCPCS Q0169
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

PROMETHAZINE TABLETS (PHENERGAN) 25 MG (TAKE HOME) [4080392]

Facility

$15.00

Service Code	HCPCS Q0169
Hospital Revenue Code	253
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$4.65
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$5.10
Rate for Payer: Hawaii Medical Service Association Medicare	$4.65
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$4.65
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$4.65
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$4.65
Rate for Payer: Ohana Health Plan Medicare	$4.65
Rate for Payer: UnitedHealthcare Medicare	$4.65
Rate for Payer: University Health Alliance Commercial	$10.93

PR OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX

Professional

Both

$1,366.00

Service Code	HCPCS 49255
Min. Negotiated Rate	$613.60
Max. Negotiated Rate	$1,161.10
Rate for Payer: AlohaCare Medicaid	$797.62
Rate for Payer: AlohaCare Medicare	$745.50
Rate for Payer: Cash Price	$819.60
Rate for Payer: Cash Price	$819.60
Rate for Payer: Devoted Health Medicare	$820.05
Rate for Payer: Hawaii Medical Service Association Medicare	$745.50
Rate for Payer: Hawaii Western Management Group Commercial	$613.60
Rate for Payer: Health Management Network Commercial	$1,161.10
Rate for Payer: Kaiser Permanente Commercial	$894.60
Rate for Payer: Kaiser Permanente Medicaid	$894.60
Rate for Payer: Kaiser Permanente Medicare	$894.60
Rate for Payer: Ohana Health Plan Medicaid	$797.62
Rate for Payer: Ohana Health Plan Medicare	$745.50
Rate for Payer: UnitedHealthcare Medicaid	$797.62
Rate for Payer: UnitedHealthcare Medicare	$745.50

PR ONDANSETRON ORAL

Professional

Both

$1.00

Service Code	HCPCS Q0162
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$51.15
Rate for Payer: AlohaCare Medicare	$0.02
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cash Price	$0.60
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$51.15
Rate for Payer: Health Management Network Commercial	$0.85
Rate for Payer: Kaiser Permanente Commercial	$0.02
Rate for Payer: Kaiser Permanente Medicaid	$0.02
Rate for Payer: Kaiser Permanente Medicare	$0.02
Rate for Payer: Ohana Health Plan Medicare	$0.02
Rate for Payer: UnitedHealthcare Medicare	$0.02

PR ONLINE DIGITAL E/M SVC EST PT <7 D 11-20 MINUTES

Professional

Both

$55.84

Service Code	HCPCS 99422
Min. Negotiated Rate	$22.41
Max. Negotiated Rate	$47.46
Rate for Payer: AlohaCare Medicaid	$25.42
Rate for Payer: AlohaCare Medicare	$22.41
Rate for Payer: Cash Price	$33.50
Rate for Payer: Cash Price	$33.50
Rate for Payer: Devoted Health Medicare	$24.65
Rate for Payer: Hawaii Medical Service Association ABD	$25.42
Rate for Payer: Hawaii Medical Service Association Commercial	$30.79
Rate for Payer: Hawaii Medical Service Association Medicare	$22.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$25.42
Rate for Payer: Hawaii Western Management Group Commercial	$32.10
Rate for Payer: Health Management Network Commercial	$47.46
Rate for Payer: Kaiser Permanente Commercial	$26.89
Rate for Payer: Kaiser Permanente Medicaid	$26.89
Rate for Payer: Kaiser Permanente Medicare	$26.89
Rate for Payer: Ohana Health Plan Medicaid	$25.42
Rate for Payer: Ohana Health Plan Medicare	$22.41
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$22.41

Know your out-of-pocket cost for care.

All Charges