Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

lisinopril 20 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904679961
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

lisinopril 40 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904720061
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

lisinopril 40 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904720061
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

lisinopril 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904581161
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

lisinopril 5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904581161
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

lithium 150 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 68462022001
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

lithium 150 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 68462022001
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

lithium 300 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 00054252725
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

lithium 300 mg Cap [KMC]

Facility

$3.00

Service Code	NDC 00054252725
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

lithium 450 mg ER Tab [KMC]

Facility

$3.00

Service Code	NDC 00054002025
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

lithium 450 mg ER Tab [KMC]

Facility

$3.00

Service Code	NDC 00054002025
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

Lithium DLS

Facility

$84.00

Service Code	HCPCS 80178
Hospital Charge Code	422801785
Hospital Revenue Code	301
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$81.48
Rate for Payer: AlohaCare Medicaid	$42.00
Rate for Payer: AlohaCare Medicare	$35.28
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$77.28
Rate for Payer: Devoted Health Medicare	$35.28
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.13
Rate for Payer: Hawaii Medical Service Association Commercial	$8.26
Rate for Payer: Hawaii Medical Service Association Medicare	$35.28
Rate for Payer: Hawaii Western Management Group Commercial	$6.61
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Humana Medicare	$35.28
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$42.84
Rate for Payer: Kaiser Permanente Medicare	$35.28
Rate for Payer: MDX Hawaii PPO	$81.48
Rate for Payer: Ohana Health Plan Medicaid	$35.28
Rate for Payer: Ohana Health Plan Medicare	$35.28
Rate for Payer: UnitedHealthcare Medicaid	$9.13
Rate for Payer: UnitedHealthcare Medicare	$35.28
Rate for Payer: University Health Alliance Commercial	$17.09

Lithium DLS

Facility

$84.00

Service Code	HCPCS 80178
Hospital Charge Code	422801785
Hospital Revenue Code	301
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$81.48
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$71.40
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: MDX Hawaii PPO	$81.48

Liver Kidney Microsome Ab, IgG DLS

Facility

$73.00

Service Code	HCPCS 86376
Hospital Charge Code	422863765
Hospital Revenue Code	302
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$36.50
Rate for Payer: AlohaCare Medicare	$30.66
Rate for Payer: Cash Price	$47.45
Rate for Payer: Cash Price	$47.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$67.16
Rate for Payer: Devoted Health Medicare	$30.66
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.11
Rate for Payer: Hawaii Medical Service Association Commercial	$18.19
Rate for Payer: Hawaii Medical Service Association Medicare	$30.66
Rate for Payer: Hawaii Western Management Group Commercial	$14.55
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$30.66
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$30.66
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$30.66
Rate for Payer: Ohana Health Plan Medicare	$30.66
Rate for Payer: UnitedHealthcare Medicaid	$20.11
Rate for Payer: UnitedHealthcare Medicare	$30.66
Rate for Payer: University Health Alliance Commercial	$37.61

Liver Kidney Microsome Ab, IgG DLS

Facility

$73.00

Service Code	HCPCS 86376
Hospital Charge Code	422863765
Hospital Revenue Code	302
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$47.45
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Kaiser Permanente Commercial	$65.70
Rate for Payer: MDX Hawaii PPO	$70.81

LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT

Facility

$358,611.26

Service Code	MSDRG 005
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$358,611.26
Rate for Payer: Hawaii Medical Service Association Commercial	$358,611.26
Rate for Payer: University Health Alliance Commercial	$10,400.00

LIVER TRANSPLANT WITHOUT MCC

Facility

$358,611.26

Service Code	MSDRG 006
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$358,611.26
Rate for Payer: Hawaii Medical Service Association Commercial	$358,611.26
Rate for Payer: University Health Alliance Commercial	$10,400.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC

Facility

$35,553.00

Service Code	MSDRG 496
Min. Negotiated Rate	$35,553.00
Max. Negotiated Rate	$35,553.00
Rate for Payer: Hawaii Medical Service Association Commercial	$35,553.00

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$38,278.73

Service Code	MSDRG 495
Min. Negotiated Rate	$38,278.73
Max. Negotiated Rate	$38,278.73
Rate for Payer: Hawaii Medical Service Association Commercial	$38,278.73

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$24,673.78

Service Code	MSDRG 497
Min. Negotiated Rate	$24,673.78
Max. Negotiated Rate	$24,673.78
Rate for Payer: Hawaii Medical Service Association Commercial	$24,673.78

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$42,971.73

Service Code	MSDRG 498
Min. Negotiated Rate	$42,971.73
Max. Negotiated Rate	$42,971.73
Rate for Payer: Hawaii Medical Service Association Commercial	$42,971.73

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$42,971.73

Service Code	MSDRG 499
Min. Negotiated Rate	$42,971.73
Max. Negotiated Rate	$42,971.73
Rate for Payer: Hawaii Medical Service Association Commercial	$42,971.73

loperamide 2 mg Cap [KMC]

Facility

$4.20

Service Code	NDC 72888013001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.07
Rate for Payer: AlohaCare Medicaid	$2.10
Rate for Payer: AlohaCare Medicare	$1.76
Rate for Payer: Cash Price	$2.73
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.86
Rate for Payer: Devoted Health Medicare	$1.76
Rate for Payer: Hawaii Medical Service Association Medicare	$1.76
Rate for Payer: Hawaii Western Management Group Commercial	$3.99
Rate for Payer: Health Management Network Commercial	$3.57
Rate for Payer: Humana Medicare	$1.76
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$2.14
Rate for Payer: Kaiser Permanente Medicare	$1.76
Rate for Payer: MDX Hawaii PPO	$4.07
Rate for Payer: Ohana Health Plan Medicaid	$1.76
Rate for Payer: Ohana Health Plan Medicare	$1.76
Rate for Payer: UnitedHealthcare Medicaid	$2.52
Rate for Payer: UnitedHealthcare Medicare	$1.76
Rate for Payer: University Health Alliance Commercial	$3.06

loperamide 2 mg Cap [KMC]

Facility

$4.20

Service Code	NDC 72888013001
Hospital Revenue Code	250
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$4.07
Rate for Payer: Cash Price	$2.73
Rate for Payer: Health Management Network Commercial	$3.57
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: MDX Hawaii PPO	$4.07

lopinavir-ritonavir 200 mg-50 mg Tab [KMC]

Facility

$28.57

Service Code	NDC 00074679922
Hospital Revenue Code	250
Min. Negotiated Rate	$24.28
Max. Negotiated Rate	$27.71
Rate for Payer: Cash Price	$18.57
Rate for Payer: Health Management Network Commercial	$24.28
Rate for Payer: Kaiser Permanente Commercial	$25.71
Rate for Payer: MDX Hawaii PPO	$27.71

Know your out-of-pocket cost for care.

All Charges