Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

LOWER EXTREMITY INFANT MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73592
Hospital Charge Code	424735920
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

LOWER EXTREMITY INFANT MIN 2 VWS

Facility

$369.00

Service Code	HCPCS 73592
Hospital Charge Code	424735920
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$56.28

LOW RISK FOR RETINOPATHY

Professional

Both

$0.01

Service Code	HCPCS 3072F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

lubiprostone 24 mcg Cap [KMC]

Facility

$26.72

Service Code	NDC 00254302902
Hospital Revenue Code	250
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$25.92
Rate for Payer: AlohaCare Medicaid	$13.36
Rate for Payer: AlohaCare Medicare	$11.22
Rate for Payer: Cash Price	$17.37
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$24.58
Rate for Payer: Devoted Health Medicare	$11.22
Rate for Payer: Hawaii Medical Service Association Medicare	$11.22
Rate for Payer: Hawaii Western Management Group Commercial	$25.38
Rate for Payer: Health Management Network Commercial	$22.71
Rate for Payer: Humana Medicare	$11.22
Rate for Payer: Kaiser Permanente Commercial	$24.05
Rate for Payer: Kaiser Permanente Medicaid	$13.63
Rate for Payer: Kaiser Permanente Medicare	$11.22
Rate for Payer: MDX Hawaii PPO	$25.92
Rate for Payer: Ohana Health Plan Medicaid	$11.22
Rate for Payer: Ohana Health Plan Medicare	$11.22
Rate for Payer: UnitedHealthcare Medicaid	$16.03
Rate for Payer: UnitedHealthcare Medicare	$11.22
Rate for Payer: University Health Alliance Commercial	$19.48

lubiprostone 24 mcg Cap [KMC]

Facility

$26.72

Service Code	NDC 00254302902
Hospital Revenue Code	250
Min. Negotiated Rate	$22.71
Max. Negotiated Rate	$25.92
Rate for Payer: Cash Price	$17.37
Rate for Payer: Health Management Network Commercial	$22.71
Rate for Payer: Kaiser Permanente Commercial	$24.05
Rate for Payer: MDX Hawaii PPO	$25.92

Lubricant jelly (Surgilube) 5gm packets [KMC]

Facility

$0.09

Service Code	NDC 00281020536
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.09
Rate for Payer: AlohaCare Medicaid	$0.05
Rate for Payer: AlohaCare Medicare	$0.04
Rate for Payer: Cash Price	$0.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.08
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Hawaii Medical Service Association Medicare	$0.04
Rate for Payer: Hawaii Western Management Group Commercial	$0.09
Rate for Payer: Health Management Network Commercial	$0.08
Rate for Payer: Humana Medicare	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.08
Rate for Payer: Kaiser Permanente Medicaid	$0.05
Rate for Payer: Kaiser Permanente Medicare	$0.04
Rate for Payer: MDX Hawaii PPO	$0.09
Rate for Payer: Ohana Health Plan Medicaid	$0.04
Rate for Payer: Ohana Health Plan Medicare	$0.04
Rate for Payer: UnitedHealthcare Medicaid	$0.05
Rate for Payer: UnitedHealthcare Medicare	$0.04
Rate for Payer: University Health Alliance Commercial	$0.07

Lubricant jelly (Surgilube) 5gm packets [KMC]

Facility

$0.09

Service Code	NDC 00281020536
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Management Network Commercial	$0.08
Rate for Payer: Kaiser Permanente Commercial	$0.08
Rate for Payer: MDX Hawaii PPO	$0.09

lumateperone 42 mg Cap [KMC]

Facility

$251.07

Service Code	NDC 72060014240
Hospital Revenue Code	250
Min. Negotiated Rate	$213.41
Max. Negotiated Rate	$243.54
Rate for Payer: Cash Price	$163.20
Rate for Payer: Health Management Network Commercial	$213.41
Rate for Payer: Kaiser Permanente Commercial	$225.96
Rate for Payer: MDX Hawaii PPO	$243.54

lumateperone 42 mg Cap [KMC]

Facility

$251.07

Service Code	NDC 72060014240
Hospital Revenue Code	250
Min. Negotiated Rate	$105.45
Max. Negotiated Rate	$243.54
Rate for Payer: AlohaCare Medicaid	$125.53
Rate for Payer: AlohaCare Medicare	$105.45
Rate for Payer: Cash Price	$163.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$230.98
Rate for Payer: Devoted Health Medicare	$105.45
Rate for Payer: Hawaii Medical Service Association Medicare	$105.45
Rate for Payer: Hawaii Western Management Group Commercial	$238.52
Rate for Payer: Health Management Network Commercial	$213.41
Rate for Payer: Humana Medicare	$105.45
Rate for Payer: Kaiser Permanente Commercial	$225.96
Rate for Payer: Kaiser Permanente Medicaid	$128.05
Rate for Payer: Kaiser Permanente Medicare	$105.45
Rate for Payer: MDX Hawaii PPO	$243.54
Rate for Payer: Ohana Health Plan Medicaid	$105.45
Rate for Payer: Ohana Health Plan Medicare	$105.45
Rate for Payer: UnitedHealthcare Medicaid	$150.64
Rate for Payer: UnitedHealthcare Medicare	$105.45
Rate for Payer: University Health Alliance Commercial	$183.00

LUMBAR PUNCTURE TRAY ADULT

Facility

$111.00

Hospital Charge Code	8172
Hospital Revenue Code	272
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$72.15
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: MDX Hawaii PPO	$107.67

LUMBAR PUNCTURE TRAY ADULT

Facility

$111.00

Hospital Charge Code	8172
Hospital Revenue Code	272
Min. Negotiated Rate	$46.62
Max. Negotiated Rate	$107.67
Rate for Payer: AlohaCare Medicaid	$55.50
Rate for Payer: AlohaCare Medicare	$46.62
Rate for Payer: Cash Price	$72.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$102.12
Rate for Payer: Devoted Health Medicare	$46.62
Rate for Payer: Hawaii Medical Service Association Medicare	$46.62
Rate for Payer: Hawaii Western Management Group Commercial	$105.45
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Humana Medicare	$46.62
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: Kaiser Permanente Medicare	$46.62
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: Ohana Health Plan Medicaid	$46.62
Rate for Payer: Ohana Health Plan Medicare	$46.62
Rate for Payer: UnitedHealthcare Medicare	$46.62
Rate for Payer: University Health Alliance Commercial	$80.91

LUMBAR PUNCTURE TRAY PED/INFANT

Facility

$543.00

Hospital Charge Code	8173
Hospital Revenue Code	272
Min. Negotiated Rate	$461.55
Max. Negotiated Rate	$526.71
Rate for Payer: Cash Price	$352.95
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Kaiser Permanente Commercial	$488.70
Rate for Payer: MDX Hawaii PPO	$526.71

LUMBAR PUNCTURE TRAY PED/INFANT

Facility

$543.00

Hospital Charge Code	8173
Hospital Revenue Code	272
Min. Negotiated Rate	$228.06
Max. Negotiated Rate	$526.71
Rate for Payer: AlohaCare Medicaid	$271.50
Rate for Payer: AlohaCare Medicare	$228.06
Rate for Payer: Cash Price	$352.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$499.56
Rate for Payer: Devoted Health Medicare	$228.06
Rate for Payer: Hawaii Medical Service Association Medicare	$228.06
Rate for Payer: Hawaii Western Management Group Commercial	$515.85
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Humana Medicare	$228.06
Rate for Payer: Kaiser Permanente Commercial	$488.70
Rate for Payer: Kaiser Permanente Medicaid	$276.93
Rate for Payer: Kaiser Permanente Medicare	$228.06
Rate for Payer: MDX Hawaii PPO	$526.71
Rate for Payer: Ohana Health Plan Medicaid	$228.06
Rate for Payer: Ohana Health Plan Medicare	$228.06
Rate for Payer: UnitedHealthcare Medicare	$228.06
Rate for Payer: University Health Alliance Commercial	$395.79

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 Tab [KMC]

Facility

$205.34

Service Code	NDC 63402030230
Hospital Revenue Code	250
Min. Negotiated Rate	$86.24
Max. Negotiated Rate	$199.18
Rate for Payer: AlohaCare Medicaid	$102.67
Rate for Payer: AlohaCare Medicare	$86.24
Rate for Payer: Cash Price	$133.47
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$188.91
Rate for Payer: Devoted Health Medicare	$86.24
Rate for Payer: Hawaii Medical Service Association Medicare	$86.24
Rate for Payer: Hawaii Western Management Group Commercial	$195.07
Rate for Payer: Health Management Network Commercial	$174.54
Rate for Payer: Humana Medicare	$86.24
Rate for Payer: Kaiser Permanente Commercial	$184.81
Rate for Payer: Kaiser Permanente Medicaid	$104.72
Rate for Payer: Kaiser Permanente Medicare	$86.24
Rate for Payer: MDX Hawaii PPO	$199.18
Rate for Payer: Ohana Health Plan Medicaid	$86.24
Rate for Payer: Ohana Health Plan Medicare	$86.24
Rate for Payer: UnitedHealthcare Medicaid	$123.20
Rate for Payer: UnitedHealthcare Medicare	$86.24
Rate for Payer: University Health Alliance Commercial	$149.67

lurasidone 20 mg Tab [KMC]

Facility

$205.34

Service Code	NDC 63402030230
Hospital Revenue Code	250
Min. Negotiated Rate	$174.54
Max. Negotiated Rate	$199.18
Rate for Payer: Cash Price	$133.47
Rate for Payer: Health Management Network Commercial	$174.54
Rate for Payer: Kaiser Permanente Commercial	$184.81
Rate for Payer: MDX Hawaii PPO	$199.18

lurasidone 40 mg Tab [KMC]

Facility

$134.21

Service Code	NDC 63402030430
Hospital Revenue Code	250
Min. Negotiated Rate	$114.08
Max. Negotiated Rate	$130.18
Rate for Payer: Cash Price	$87.24
Rate for Payer: Health Management Network Commercial	$114.08
Rate for Payer: Kaiser Permanente Commercial	$120.79
Rate for Payer: MDX Hawaii PPO	$130.18

lurasidone 40 mg Tab [KMC]

Facility

$134.21

Service Code	NDC 63402030430
Hospital Revenue Code	250
Min. Negotiated Rate	$56.37
Max. Negotiated Rate	$130.18
Rate for Payer: AlohaCare Medicaid	$67.11
Rate for Payer: AlohaCare Medicare	$56.37
Rate for Payer: Cash Price	$87.24
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$123.47
Rate for Payer: Devoted Health Medicare	$56.37
Rate for Payer: Hawaii Medical Service Association Medicare	$56.37
Rate for Payer: Hawaii Western Management Group Commercial	$127.50
Rate for Payer: Health Management Network Commercial	$114.08
Rate for Payer: Humana Medicare	$56.37
Rate for Payer: Kaiser Permanente Commercial	$120.79
Rate for Payer: Kaiser Permanente Medicaid	$68.45
Rate for Payer: Kaiser Permanente Medicare	$56.37
Rate for Payer: MDX Hawaii PPO	$130.18
Rate for Payer: Ohana Health Plan Medicaid	$56.37
Rate for Payer: Ohana Health Plan Medicare	$56.37
Rate for Payer: UnitedHealthcare Medicaid	$80.53
Rate for Payer: UnitedHealthcare Medicare	$56.37
Rate for Payer: University Health Alliance Commercial	$97.83

lurasidone 60 mg Tab [KMC]

Facility

$202.02

Service Code	NDC 72205020930
Hospital Revenue Code	250
Min. Negotiated Rate	$171.72
Max. Negotiated Rate	$195.96
Rate for Payer: Cash Price	$131.31
Rate for Payer: Health Management Network Commercial	$171.72
Rate for Payer: Kaiser Permanente Commercial	$181.82
Rate for Payer: MDX Hawaii PPO	$195.96

lurasidone 60 mg Tab [KMC]

Facility

$202.02

Service Code	NDC 72205020930
Hospital Revenue Code	250
Min. Negotiated Rate	$84.85
Max. Negotiated Rate	$195.96
Rate for Payer: AlohaCare Medicaid	$101.01
Rate for Payer: AlohaCare Medicare	$84.85
Rate for Payer: Cash Price	$131.31
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$185.86
Rate for Payer: Devoted Health Medicare	$84.85
Rate for Payer: Hawaii Medical Service Association Medicare	$84.85
Rate for Payer: Hawaii Western Management Group Commercial	$191.92
Rate for Payer: Health Management Network Commercial	$171.72
Rate for Payer: Humana Medicare	$84.85
Rate for Payer: Kaiser Permanente Commercial	$181.82
Rate for Payer: Kaiser Permanente Medicaid	$103.03
Rate for Payer: Kaiser Permanente Medicare	$84.85
Rate for Payer: MDX Hawaii PPO	$195.96
Rate for Payer: Ohana Health Plan Medicaid	$84.85
Rate for Payer: Ohana Health Plan Medicare	$84.85
Rate for Payer: UnitedHealthcare Medicaid	$121.21
Rate for Payer: UnitedHealthcare Medicare	$84.85
Rate for Payer: University Health Alliance Commercial	$147.25

lurasidone 80 mg Tab [KMC]

Facility

$226.99

Service Code	NDC 63402030830
Hospital Revenue Code	250
Min. Negotiated Rate	$192.94
Max. Negotiated Rate	$220.18
Rate for Payer: Cash Price	$147.54
Rate for Payer: Health Management Network Commercial	$192.94
Rate for Payer: Kaiser Permanente Commercial	$204.29
Rate for Payer: MDX Hawaii PPO	$220.18

lurasidone 80 mg Tab [KMC]

Facility

$226.99

Service Code	NDC 63402030830
Hospital Revenue Code	250
Min. Negotiated Rate	$95.34
Max. Negotiated Rate	$220.18
Rate for Payer: AlohaCare Medicaid	$113.50
Rate for Payer: AlohaCare Medicare	$95.34
Rate for Payer: Cash Price	$147.54
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$208.83
Rate for Payer: Devoted Health Medicare	$95.34
Rate for Payer: Hawaii Medical Service Association Medicare	$95.34
Rate for Payer: Hawaii Western Management Group Commercial	$215.64
Rate for Payer: Health Management Network Commercial	$192.94
Rate for Payer: Humana Medicare	$95.34
Rate for Payer: Kaiser Permanente Commercial	$204.29
Rate for Payer: Kaiser Permanente Medicaid	$115.76
Rate for Payer: Kaiser Permanente Medicare	$95.34
Rate for Payer: MDX Hawaii PPO	$220.18
Rate for Payer: Ohana Health Plan Medicaid	$95.34
Rate for Payer: Ohana Health Plan Medicare	$95.34
Rate for Payer: UnitedHealthcare Medicaid	$136.19
Rate for Payer: UnitedHealthcare Medicare	$95.34
Rate for Payer: University Health Alliance Commercial	$165.45

Know your out-of-pocket cost for care.

All Charges