Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

lidocaine Top 5% patch [KMC]

Facility

$53.81

Service Code	NDC 42291049530
Hospital Revenue Code	250
Min. Negotiated Rate	$22.60
Max. Negotiated Rate	$52.20
Rate for Payer: AlohaCare Medicaid	$26.91
Rate for Payer: AlohaCare Medicare	$22.60
Rate for Payer: Cash Price	$34.98
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$49.51
Rate for Payer: Devoted Health Medicare	$22.60
Rate for Payer: Hawaii Medical Service Association Medicare	$22.60
Rate for Payer: Hawaii Western Management Group Commercial	$51.12
Rate for Payer: Health Management Network Commercial	$45.74
Rate for Payer: Humana Medicare	$22.60
Rate for Payer: Kaiser Permanente Commercial	$48.43
Rate for Payer: Kaiser Permanente Medicaid	$27.44
Rate for Payer: Kaiser Permanente Medicare	$22.60
Rate for Payer: MDX Hawaii PPO	$52.20
Rate for Payer: Ohana Health Plan Medicaid	$22.60
Rate for Payer: Ohana Health Plan Medicare	$22.60
Rate for Payer: UnitedHealthcare Medicaid	$32.29
Rate for Payer: UnitedHealthcare Medicare	$22.60
Rate for Payer: University Health Alliance Commercial	$39.22

lidocaine Top 5% patch [KMC]

Facility

$53.81

Service Code	NDC 42291049530
Hospital Revenue Code	250
Min. Negotiated Rate	$45.74
Max. Negotiated Rate	$52.20
Rate for Payer: Cash Price	$34.98
Rate for Payer: Health Management Network Commercial	$45.74
Rate for Payer: Kaiser Permanente Commercial	$48.43
Rate for Payer: MDX Hawaii PPO	$52.20

lifitegrast ophthalmic 5% Soln [KMC]

Facility

$54.76

Service Code	NDC 00078091112
Hospital Revenue Code	250
Min. Negotiated Rate	$23.00
Max. Negotiated Rate	$53.12
Rate for Payer: AlohaCare Medicaid	$27.38
Rate for Payer: AlohaCare Medicare	$23.00
Rate for Payer: Cash Price	$35.59
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$50.38
Rate for Payer: Devoted Health Medicare	$23.00
Rate for Payer: Hawaii Medical Service Association Medicare	$23.00
Rate for Payer: Hawaii Western Management Group Commercial	$52.02
Rate for Payer: Health Management Network Commercial	$46.55
Rate for Payer: Humana Medicare	$23.00
Rate for Payer: Kaiser Permanente Commercial	$49.28
Rate for Payer: Kaiser Permanente Medicaid	$27.93
Rate for Payer: Kaiser Permanente Medicare	$23.00
Rate for Payer: MDX Hawaii PPO	$53.12
Rate for Payer: Ohana Health Plan Medicaid	$23.00
Rate for Payer: Ohana Health Plan Medicare	$23.00
Rate for Payer: UnitedHealthcare Medicaid	$32.86
Rate for Payer: UnitedHealthcare Medicare	$23.00
Rate for Payer: University Health Alliance Commercial	$39.91

lifitegrast ophthalmic 5% Soln [KMC]

Facility

$54.76

Service Code	NDC 00078091112
Hospital Revenue Code	250
Min. Negotiated Rate	$46.55
Max. Negotiated Rate	$53.12
Rate for Payer: Cash Price	$35.59
Rate for Payer: Health Management Network Commercial	$46.55
Rate for Payer: Kaiser Permanente Commercial	$49.28
Rate for Payer: MDX Hawaii PPO	$53.12

LIMB MUSCLE TEST, MANUAL

Professional

Both

$164.00

Service Code	HCPCS 95831
Hospital Revenue Code	420
Min. Negotiated Rate	$22.98
Max. Negotiated Rate	$139.40
Rate for Payer: Cash Price	$106.60
Rate for Payer: Cash Price	$106.60
Rate for Payer: Hawaii Western Management Group Commercial	$22.98
Rate for Payer: Health Management Network Commercial	$139.40

LIMB MUSC TESTING MANUAL Occupational

Facility

$173.00

Service Code	HCPCS 95831 GO
Hospital Charge Code	432958310
Hospital Revenue Code	430
Min. Negotiated Rate	$72.66
Max. Negotiated Rate	$167.81
Rate for Payer: AlohaCare Medicaid	$86.50
Rate for Payer: AlohaCare Medicare	$72.66
Rate for Payer: Cash Price	$112.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$159.16
Rate for Payer: Devoted Health Medicare	$72.66
Rate for Payer: Hawaii Medical Service Association Medicare	$72.66
Rate for Payer: Hawaii Western Management Group Commercial	$164.35
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Humana Medicare	$72.66
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: Kaiser Permanente Medicaid	$88.23
Rate for Payer: Kaiser Permanente Medicare	$72.66
Rate for Payer: MDX Hawaii PPO	$167.81
Rate for Payer: Ohana Health Plan Medicaid	$72.66
Rate for Payer: Ohana Health Plan Medicare	$72.66
Rate for Payer: UnitedHealthcare Medicare	$72.66
Rate for Payer: University Health Alliance Commercial	$126.10

LIMB MUSC TESTING MANUAL Occupational

Facility

$173.00

Service Code	HCPCS 95831 GO
Hospital Charge Code	432958310
Hospital Revenue Code	430
Min. Negotiated Rate	$147.05
Max. Negotiated Rate	$167.81
Rate for Payer: Cash Price	$112.45
Rate for Payer: Health Management Network Commercial	$147.05
Rate for Payer: Kaiser Permanente Commercial	$155.70
Rate for Payer: MDX Hawaii PPO	$167.81

LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA

Facility

$214,242.38

Service Code	MSDRG 956
Min. Negotiated Rate	$214,242.38
Max. Negotiated Rate	$214,242.38
Rate for Payer: Hawaii Medical Service Association Commercial	$214,242.38

Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis

Facility

$54.00

Service Code	HCPCS 93922
Hospital Charge Code	424939229
Hospital Revenue Code	972
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$196.47
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$22.68
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$49.68
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$68.30
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$22.68
Rate for Payer: Hawaii Western Management Group Commercial	$51.30
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$22.68
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$22.68
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$22.68
Rate for Payer: Ohana Health Plan Medicare	$22.68
Rate for Payer: UnitedHealthcare Medicaid	$68.30
Rate for Payer: UnitedHealthcare Medicare	$22.68
Rate for Payer: University Health Alliance Commercial	$39.36

Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis

Facility

$54.00

Service Code	HCPCS 93922
Hospital Charge Code	424939229
Hospital Revenue Code	972
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis a

Facility

$51.00

Service Code	HCPCS 93922
Hospital Charge Code	424939229
Hospital Revenue Code	972
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

Facility

$51.00

Service Code	HCPCS 93922
Hospital Charge Code	424939229
Hospital Revenue Code	972
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$196.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$21.42
Rate for Payer: Cash Price	$33.15
Rate for Payer: Cash Price	$33.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.92
Rate for Payer: Devoted Health Medicare	$21.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$68.30
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$21.42
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$21.42
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$21.42
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$21.42
Rate for Payer: Ohana Health Plan Medicare	$21.42
Rate for Payer: UnitedHealthcare Medicaid	$68.30
Rate for Payer: UnitedHealthcare Medicare	$21.42
Rate for Payer: University Health Alliance Commercial	$37.17

linaclotide 145 mcg Cap [KMC]

Facility

$71.20

Service Code	NDC 00456120130
Hospital Revenue Code	250
Min. Negotiated Rate	$60.52
Max. Negotiated Rate	$69.06
Rate for Payer: Cash Price	$46.28
Rate for Payer: Health Management Network Commercial	$60.52
Rate for Payer: Kaiser Permanente Commercial	$64.08
Rate for Payer: MDX Hawaii PPO	$69.06

linaclotide 145 mcg Cap [KMC]

Facility

$71.20

Service Code	NDC 00456120130
Hospital Revenue Code	250
Min. Negotiated Rate	$29.90
Max. Negotiated Rate	$69.06
Rate for Payer: AlohaCare Medicaid	$35.60
Rate for Payer: AlohaCare Medicare	$29.90
Rate for Payer: Cash Price	$46.28
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$65.50
Rate for Payer: Devoted Health Medicare	$29.90
Rate for Payer: Hawaii Medical Service Association Medicare	$29.90
Rate for Payer: Hawaii Western Management Group Commercial	$67.64
Rate for Payer: Health Management Network Commercial	$60.52
Rate for Payer: Humana Medicare	$29.90
Rate for Payer: Kaiser Permanente Commercial	$64.08
Rate for Payer: Kaiser Permanente Medicaid	$36.31
Rate for Payer: Kaiser Permanente Medicare	$29.90
Rate for Payer: MDX Hawaii PPO	$69.06
Rate for Payer: Ohana Health Plan Medicaid	$29.90
Rate for Payer: Ohana Health Plan Medicare	$29.90
Rate for Payer: UnitedHealthcare Medicaid	$42.72
Rate for Payer: UnitedHealthcare Medicare	$29.90
Rate for Payer: University Health Alliance Commercial	$51.90

linaclotide 290 mcg Cap [KMC]

Facility

$78.50

Service Code	NDC 00456120230
Hospital Revenue Code	250
Min. Negotiated Rate	$32.97
Max. Negotiated Rate	$76.14
Rate for Payer: AlohaCare Medicaid	$39.25
Rate for Payer: AlohaCare Medicare	$32.97
Rate for Payer: Cash Price	$51.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$72.22
Rate for Payer: Devoted Health Medicare	$32.97
Rate for Payer: Hawaii Medical Service Association Medicare	$32.97
Rate for Payer: Hawaii Western Management Group Commercial	$74.58
Rate for Payer: Health Management Network Commercial	$66.72
Rate for Payer: Humana Medicare	$32.97
Rate for Payer: Kaiser Permanente Commercial	$70.65
Rate for Payer: Kaiser Permanente Medicaid	$40.03
Rate for Payer: Kaiser Permanente Medicare	$32.97
Rate for Payer: MDX Hawaii PPO	$76.14
Rate for Payer: Ohana Health Plan Medicaid	$32.97
Rate for Payer: Ohana Health Plan Medicare	$32.97
Rate for Payer: UnitedHealthcare Medicaid	$47.10
Rate for Payer: UnitedHealthcare Medicare	$32.97
Rate for Payer: University Health Alliance Commercial	$57.22

linaclotide 290 mcg Cap [KMC]

Facility

$78.50

Service Code	NDC 00456120230
Hospital Revenue Code	250
Min. Negotiated Rate	$66.72
Max. Negotiated Rate	$76.14
Rate for Payer: Cash Price	$51.02
Rate for Payer: Health Management Network Commercial	$66.72
Rate for Payer: Kaiser Permanente Commercial	$70.65
Rate for Payer: MDX Hawaii PPO	$76.14

linaclotide 72 mcg Cap [KMC]

Facility

$82.43

Service Code	NDC 00456120330
Hospital Revenue Code	250
Min. Negotiated Rate	$34.62
Max. Negotiated Rate	$79.96
Rate for Payer: AlohaCare Medicaid	$41.22
Rate for Payer: AlohaCare Medicare	$34.62
Rate for Payer: Cash Price	$53.58
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$75.84
Rate for Payer: Devoted Health Medicare	$34.62
Rate for Payer: Hawaii Medical Service Association Medicare	$34.62
Rate for Payer: Hawaii Western Management Group Commercial	$78.31
Rate for Payer: Health Management Network Commercial	$70.07
Rate for Payer: Humana Medicare	$34.62
Rate for Payer: Kaiser Permanente Commercial	$74.19
Rate for Payer: Kaiser Permanente Medicaid	$42.04
Rate for Payer: Kaiser Permanente Medicare	$34.62
Rate for Payer: MDX Hawaii PPO	$79.96
Rate for Payer: Ohana Health Plan Medicaid	$34.62
Rate for Payer: Ohana Health Plan Medicare	$34.62
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$34.62
Rate for Payer: University Health Alliance Commercial	$60.08

linaclotide 72 mcg Cap [KMC]

Facility

$82.43

Service Code	NDC 00456120330
Hospital Revenue Code	250
Min. Negotiated Rate	$70.07
Max. Negotiated Rate	$79.96
Rate for Payer: Cash Price	$53.58
Rate for Payer: Health Management Network Commercial	$70.07
Rate for Payer: Kaiser Permanente Commercial	$74.19
Rate for Payer: MDX Hawaii PPO	$79.96

linagliptin 5 mg Tab [KMC]

Facility

$36.92

Service Code	NDC 00597014030
Hospital Revenue Code	250
Min. Negotiated Rate	$15.51
Max. Negotiated Rate	$35.81
Rate for Payer: AlohaCare Medicaid	$18.46
Rate for Payer: AlohaCare Medicare	$15.51
Rate for Payer: Cash Price	$24.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$33.97
Rate for Payer: Devoted Health Medicare	$15.51
Rate for Payer: Hawaii Medical Service Association Medicare	$15.51
Rate for Payer: Hawaii Western Management Group Commercial	$35.07
Rate for Payer: Health Management Network Commercial	$31.38
Rate for Payer: Humana Medicare	$15.51
Rate for Payer: Kaiser Permanente Commercial	$33.23
Rate for Payer: Kaiser Permanente Medicaid	$18.83
Rate for Payer: Kaiser Permanente Medicare	$15.51
Rate for Payer: MDX Hawaii PPO	$35.81
Rate for Payer: Ohana Health Plan Medicaid	$15.51
Rate for Payer: Ohana Health Plan Medicare	$15.51
Rate for Payer: UnitedHealthcare Medicaid	$22.15
Rate for Payer: UnitedHealthcare Medicare	$15.51
Rate for Payer: University Health Alliance Commercial	$26.91

linagliptin 5 mg Tab [KMC]

Facility

$36.92

Service Code	NDC 00597014030
Hospital Revenue Code	250
Min. Negotiated Rate	$31.38
Max. Negotiated Rate	$35.81
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$31.38
Rate for Payer: Kaiser Permanente Commercial	$33.23
Rate for Payer: MDX Hawaii PPO	$35.81

Linezolid 600 mg / 300 mL D5W soln [KMC]

Facility

$0.77

Service Code	HCPCS J2020
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.50
Rate for Payer: Health Management Network Commercial	$0.65
Rate for Payer: Kaiser Permanente Commercial	$0.69
Rate for Payer: MDX Hawaii PPO	$0.75

Linezolid 600 mg / 300 mL D5W soln [KMC]

Facility

$0.77

Service Code	HCPCS J2020
Hospital Revenue Code	636
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$3.47
Rate for Payer: AlohaCare Medicaid	$0.39
Rate for Payer: AlohaCare Medicare	$0.32
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cash Price	$0.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.71
Rate for Payer: Devoted Health Medicare	$0.32
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$3.47
Rate for Payer: Hawaii Medical Service Association Medicare	$0.32
Rate for Payer: Hawaii Western Management Group Commercial	$0.73
Rate for Payer: Health Management Network Commercial	$0.65
Rate for Payer: Humana Medicare	$0.32
Rate for Payer: Kaiser Permanente Commercial	$0.69
Rate for Payer: Kaiser Permanente Medicaid	$0.39
Rate for Payer: Kaiser Permanente Medicare	$0.32
Rate for Payer: MDX Hawaii PPO	$0.75
Rate for Payer: Ohana Health Plan Medicaid	$0.32
Rate for Payer: Ohana Health Plan Medicare	$0.32
Rate for Payer: UnitedHealthcare Medicaid	$0.46
Rate for Payer: UnitedHealthcare Medicare	$0.32
Rate for Payer: University Health Alliance Commercial	$0.56

linezolid 600 mg Tab [KMC]

Facility

$734.68

Service Code	NDC 31722074920
Hospital Revenue Code	250
Min. Negotiated Rate	$624.48
Max. Negotiated Rate	$712.64
Rate for Payer: Cash Price	$477.54
Rate for Payer: Health Management Network Commercial	$624.48
Rate for Payer: Kaiser Permanente Commercial	$661.21
Rate for Payer: MDX Hawaii PPO	$712.64

linezolid 600 mg Tab [KMC]

Facility

$734.68

Service Code	NDC 31722074920
Hospital Revenue Code	250
Min. Negotiated Rate	$308.57
Max. Negotiated Rate	$712.64
Rate for Payer: AlohaCare Medicaid	$367.34
Rate for Payer: AlohaCare Medicare	$308.57
Rate for Payer: Cash Price	$477.54
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$675.91
Rate for Payer: Devoted Health Medicare	$308.57
Rate for Payer: Hawaii Medical Service Association Medicare	$308.57
Rate for Payer: Hawaii Western Management Group Commercial	$697.95
Rate for Payer: Health Management Network Commercial	$624.48
Rate for Payer: Humana Medicare	$308.57
Rate for Payer: Kaiser Permanente Commercial	$661.21
Rate for Payer: Kaiser Permanente Medicaid	$374.69
Rate for Payer: Kaiser Permanente Medicare	$308.57
Rate for Payer: MDX Hawaii PPO	$712.64
Rate for Payer: Ohana Health Plan Medicaid	$308.57
Rate for Payer: Ohana Health Plan Medicare	$308.57
Rate for Payer: UnitedHealthcare Medicaid	$440.81
Rate for Payer: UnitedHealthcare Medicare	$308.57
Rate for Payer: University Health Alliance Commercial	$535.51

liothyronine 25 mcg Tab [KMC]

Facility

$3.00

Service Code	NDC 60793011601
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

Know your out-of-pocket cost for care.

All Charges