Kau Hospital

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 112 MCG TABLET [10404]

Facility

$3.00

Service Code	NDC 68180097001
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

LEVOTHYROXINE 112 MCG TABLET [10404]

Facility

$3.00

Service Code	NDC 42292003901
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

LEVOTHYROXINE 112 MCG TABLET [10404]

Facility

$3.00

Service Code	NDC 60687050801
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

LEVOTHYROXINE 112 MCG TABLET [10404]

Facility

$3.00

Service Code	NDC 42292003901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

LEVOTHYROXINE 112 MCG TABLET [10404]

Facility

$3.00

Service Code	NDC 68180097001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

LEVOTHYROXINE 125 MCG TABLET [4424]

Facility

$3.00

Service Code	NDC 60687051901
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

LEVOTHYROXINE 125 MCG TABLET [4424]

Facility

$3.00

Service Code	NDC 60687051911
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

LEVOTHYROXINE 125 MCG TABLET [4424]

Facility

$3.00

Service Code	NDC 60687051911
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

LEVOTHYROXINE 125 MCG TABLET [4424]

Facility

$3.00

Service Code	NDC 60687051901
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

LEVOTHYROXINE 150 MCG TABLET [4425]

Facility

$3.00

Service Code	NDC 68180097301
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

LEVOTHYROXINE 150 MCG TABLET [4425]

Facility

$3.00

Service Code	NDC 68180097301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

LEVOTHYROXINE 175 MCG TABLET [10406]

Facility

$3.00

Service Code	NDC 68180097401
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$0.93
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$1.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.93
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$0.93
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$0.93
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$0.93
Rate for Payer: Ohana Health Plan Medicare	$0.93
Rate for Payer: UnitedHealthcare Medicare	$0.93
Rate for Payer: University Health Alliance Commercial	$2.19

LEVOTHYROXINE 175 MCG TABLET [10406]

Facility

$3.00

Service Code	NDC 68180097401
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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

LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION [167874]

Facility

$267.00

Service Code	HCPCS J0651
Hospital Revenue Code	250
Min. Negotiated Rate	$226.95
Max. Negotiated Rate	$258.99
Rate for Payer: Cash Price	$160.20
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Health Management Network Commercial	$226.95
Rate for Payer: Kaiser Permanente Commercial	$240.30
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$258.99
Rate for Payer: MDX Hawaii PPO	$61.11

LEVOTHYROXINE 25 MCG TABLET [4420]

Facility

$2.00

Service Code	NDC 60687045311
Hospital Revenue Code	637
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 Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

LEVOTHYROXINE 25 MCG TABLET [4420]

Facility

$2.00

Service Code	NDC 60687045301
Hospital Revenue Code	637
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 Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

LEVOTHYROXINE 25 MCG TABLET [4420]

Facility

$2.00

Service Code	NDC 60687045311
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

LEVOTHYROXINE 25 MCG TABLET [4420]

Facility

$2.00

Service Code	NDC 60687045301
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

LEVOTHYROXINE 50 MCG TABLET [4421]

Facility

$2.00

Service Code	NDC 60687046401
Hospital Revenue Code	637
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 Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

LEVOTHYROXINE 50 MCG TABLET [4421]

Facility

$2.00

Service Code	NDC 51079044020
Hospital Revenue Code	637
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 Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

LEVOTHYROXINE 50 MCG TABLET [4421]

Facility

$2.00

Service Code	NDC 60687046401
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

LEVOTHYROXINE 50 MCG TABLET [4421]

Facility

$2.00

Service Code	NDC 60687046411
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

LEVOTHYROXINE 50 MCG TABLET [4421]

Facility

$2.00

Service Code	NDC 60687046411
Hospital Revenue Code	637
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 Medicare	$0.62
Rate for Payer: University Health Alliance Commercial	$1.46

LEVOTHYROXINE 50 MCG TABLET [4421]

Facility

$2.00

Service Code	NDC 51079044020
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

LEVOTHYROXINE 75 MCG TABLET [4422]

Facility

$3.00

Service Code	NDC 60687047501
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
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