Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

LOSARTAN 100 MG TABLET [22588]

Facility

$11.00

Service Code	NDC 68084034811
Hospital Revenue Code	250
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$6.60
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

LOSARTAN 100 MG TABLET [22588]

Facility

$11.00

Service Code	NDC 68084034811
Hospital Revenue Code	637
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$8.36
Rate for Payer: Cash Price	$6.60
Rate for Payer: Devoted Health Medicare	$9.24
Rate for Payer: Hawaii Medical Service Association Medicare	$8.36
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$8.36
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$8.36
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$8.36
Rate for Payer: Ohana Health Plan Medicare	$8.36
Rate for Payer: UnitedHealthcare Medicare	$8.36
Rate for Payer: University Health Alliance Commercial	$8.02

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034611
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034601
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034611
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

LOSARTAN 25 MG TABLET [14823]

Facility

$6.00

Service Code	NDC 68084034601
Hospital Revenue Code	637
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$4.56
Rate for Payer: Cash Price	$3.60
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$4.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$4.56
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$4.56
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$4.56
Rate for Payer: Ohana Health Plan Medicare	$4.56
Rate for Payer: UnitedHealthcare Medicare	$4.56
Rate for Payer: University Health Alliance Commercial	$4.37

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034701
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

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034701
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$6.08
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$6.72
Rate for Payer: Hawaii Medical Service Association Medicare	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$6.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$6.08
Rate for Payer: UnitedHealthcare Medicare	$6.08
Rate for Payer: University Health Alliance Commercial	$5.83

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034711
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

LOSARTAN 50 MG TABLET [14824]

Facility

$8.00

Service Code	NDC 68084034711
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$6.08
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$6.72
Rate for Payer: Hawaii Medical Service Association Medicare	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$6.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$6.08
Rate for Payer: UnitedHealthcare Medicare	$6.08
Rate for Payer: University Health Alliance Commercial	$5.83

LOSARTAN TABLETS (COZAAR) 25 MG (TAKE HOME) [4080371]

Facility

$15.00

Service Code	NDC 00004080159
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

LOSARTAN TABLETS (COZAAR) 25 MG (TAKE HOME) [4080371]

Facility

$15.00

Service Code	NDC 00004080159
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$54,751.62

Service Code	MSDRG 493
Min. Negotiated Rate	$54,751.62
Max. Negotiated Rate	$54,751.62
Rate for Payer: Hawaii Medical Service Association Commercial	$54,751.62

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$54,751.62

Service Code	MSDRG 492
Min. Negotiated Rate	$54,751.62
Max. Negotiated Rate	$54,751.62
Rate for Payer: Hawaii Medical Service Association Commercial	$54,751.62

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$32,329.53

Service Code	MSDRG 494
Min. Negotiated Rate	$32,329.53
Max. Negotiated Rate	$32,329.53
Rate for Payer: Hawaii Medical Service Association Commercial	$32,329.53

LOW INTENSITY HEPARIN CALCULATOR BOLUS [4080207]

Facility

$17.00

Service Code	HCPCS J1644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicaid	$15.50
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$23.56
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: AlohaCare Medicare	$12.92
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$26.04
Rate for Payer: Devoted Health Medicare	$14.28
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Medicare	$12.92
Rate for Payer: Hawaii Medical Service Association Medicare	$23.56
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.22
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Humana Medicare	$12.92
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Humana Medicare	$23.56
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$12.92
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: Kaiser Permanente Medicare	$23.56
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$12.92
Rate for Payer: Ohana Health Plan Medicaid	$23.56
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$23.56
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: Ohana Health Plan Medicare	$12.92
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: UnitedHealthcare Medicaid	$18.60
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$23.56
Rate for Payer: UnitedHealthcare Medicare	$12.92
Rate for Payer: University Health Alliance Commercial	$22.60
Rate for Payer: University Health Alliance Commercial	$12.39
Rate for Payer: University Health Alliance Commercial	$10.93

LOW INTENSITY HEPARIN CALCULATOR BOLUS [4080207]

Facility

$15.00

Service Code	HCPCS J1644
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$18.60
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Commercial	$27.90
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$16.49

LUNG TRANSPLANT

Facility

$10,400.00

Service Code	MSDRG 007
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$10,400.00
Rate for Payer: University Health Alliance Commercial	$10,400.00

LURASIDONE 20 MG TABLET [113587]

Facility

$95.00

Service Code	NDC 62332049430
Hospital Revenue Code	250
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

LURASIDONE 20 MG TABLET [113587]

Facility

$95.00

Service Code	NDC 62332049430
Hospital Revenue Code	637
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$72.20
Rate for Payer: Cash Price	$57.00
Rate for Payer: Devoted Health Medicare	$79.80
Rate for Payer: Hawaii Medical Service Association Medicare	$72.20
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$72.20
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$72.20
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$72.20
Rate for Payer: Ohana Health Plan Medicare	$72.20
Rate for Payer: UnitedHealthcare Medicare	$72.20
Rate for Payer: University Health Alliance Commercial	$69.25

LURASIDONE 40 MG TABLET [107668]

Facility

$103.00

Service Code	NDC 47335068483
Hospital Revenue Code	637
Min. Negotiated Rate	$51.50
Max. Negotiated Rate	$99.91
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$78.28
Rate for Payer: Cash Price	$61.80
Rate for Payer: Devoted Health Medicare	$86.52
Rate for Payer: Hawaii Medical Service Association Medicare	$78.28
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$78.28
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$78.28
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$78.28
Rate for Payer: Ohana Health Plan Medicare	$78.28
Rate for Payer: UnitedHealthcare Medicare	$78.28
Rate for Payer: University Health Alliance Commercial	$75.08

LURASIDONE 40 MG TABLET [107668]

Facility

$103.00

Service Code	NDC 47335068483
Hospital Revenue Code	250
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: MDX Hawaii PPO	$99.91

LURASIDONE 40 MG TABLET [107668]

Facility

$95.00

Service Code	NDC 62332049530
Hospital Revenue Code	250
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: MDX Hawaii PPO	$92.15

LURASIDONE 40 MG TABLET [107668]

Facility

$95.00

Service Code	NDC 62332049530
Hospital Revenue Code	637
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$47.50
Rate for Payer: AlohaCare Medicare	$72.20
Rate for Payer: Cash Price	$57.00
Rate for Payer: Devoted Health Medicare	$79.80
Rate for Payer: Hawaii Medical Service Association Medicare	$72.20
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$72.20
Rate for Payer: Kaiser Permanente Commercial	$85.50
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$72.20
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$72.20
Rate for Payer: Ohana Health Plan Medicare	$72.20
Rate for Payer: UnitedHealthcare Medicare	$72.20
Rate for Payer: University Health Alliance Commercial	$69.25

LURBINECTEDIN 4 MG/8 ML IV (WET SOLR VIAL) [430173604]

Facility

$10,400.00

Service Code	HCPCS J9223
Hospital Revenue Code	636
Min. Negotiated Rate	$206.13
Max. Negotiated Rate	$10,088.00
Rate for Payer: AlohaCare Medicaid	$5,200.00
Rate for Payer: AlohaCare Medicare	$7,904.00
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Cash Price	$6,240.00
Rate for Payer: Devoted Health Medicare	$8,736.00
Rate for Payer: Hawaii Medical Service Association ABD	$206.13
Rate for Payer: Hawaii Medical Service Association Commercial	$265.12
Rate for Payer: Hawaii Medical Service Association Medicare	$7,904.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$206.13
Rate for Payer: Hawaii Western Management Group Commercial	$9,880.00
Rate for Payer: Health Management Network Commercial	$8,840.00
Rate for Payer: Humana Medicare	$7,904.00
Rate for Payer: Kaiser Permanente Commercial	$9,360.00
Rate for Payer: Kaiser Permanente Medicaid	$5,304.00
Rate for Payer: Kaiser Permanente Medicare	$7,904.00
Rate for Payer: MDX Hawaii PPO	$10,088.00
Rate for Payer: Ohana Health Plan Medicaid	$7,904.00
Rate for Payer: Ohana Health Plan Medicare	$7,904.00
Rate for Payer: UnitedHealthcare Medicaid	$6,240.00
Rate for Payer: UnitedHealthcare Medicare	$7,904.00
Rate for Payer: University Health Alliance Commercial	$7,580.56

Know your out-of-pocket cost for care.

All Charges