Kau Hospital

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 75 MCG TABLET [4422]

Facility

$3.00

Service Code	NDC 60687047511
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 75 MCG TABLET [4422]

Facility

$2.00

Service Code	NDC 00527328246
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 75 MCG TABLET [4422]

Facility

$3.00

Service Code	NDC 51079044120
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 75 MCG TABLET [4422]

Facility

$3.00

Service Code	NDC 60687047511
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 75 MCG TABLET [4422]

Facility

$2.00

Service Code	NDC 00527328246
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	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 75 MCG TABLET [4422]

Facility

$3.00

Service Code	NDC 51079044120
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 88 MCG TABLET [10403]

Facility

$3.00

Service Code	NDC 60687048601
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 88 MCG TABLET [10403]

Facility

$3.00

Service Code	NDC 60687048611
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 88 MCG TABLET [10403]

Facility

$3.00

Service Code	NDC 42292003820
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 88 MCG TABLET [10403]

Facility

$3.00

Service Code	NDC 60687048601
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 88 MCG TABLET [10403]

Facility

$3.00

Service Code	NDC 60687048611
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 88 MCG TABLET [10403]

Facility

$3.00

Service Code	NDC 42292003820
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

LFIT V40 FEMORAL HD 6260-9-128

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.76
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: Kaiser Permanente Commercial	$1,773.90
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

LFIT V40 FEMORAL HD 6260-9-128

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$611.01
Max. Negotiated Rate	$1,911.87
Rate for Payer: AlohaCare Medicaid	$985.50
Rate for Payer: AlohaCare Medicare	$611.01
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Devoted Health Medicare	$670.14
Rate for Payer: Hawaii Medical Service Association Medicare	$611.01
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: Humana Medicare	$611.01
Rate for Payer: Kaiser Permanente Commercial	$1,773.90
Rate for Payer: Kaiser Permanente Medicaid	$1,005.21
Rate for Payer: Kaiser Permanente Medicare	$611.01
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: Ohana Health Plan Medicaid	$611.01
Rate for Payer: Ohana Health Plan Medicare	$611.01
Rate for Payer: UnitedHealthcare Medicare	$611.01
Rate for Payer: University Health Alliance Commercial	$1,103.76

LFITV40 FH 22.2MM 6260-9-122

Facility

$1,990.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$616.90
Max. Negotiated Rate	$1,930.30
Rate for Payer: AlohaCare Medicaid	$995.00
Rate for Payer: AlohaCare Medicare	$616.90
Rate for Payer: Cash Price	$1,194.00
Rate for Payer: Devoted Health Medicare	$676.60
Rate for Payer: Hawaii Medical Service Association Medicare	$616.90
Rate for Payer: Hawaii Western Management Group Commercial	$1,393.00
Rate for Payer: Health Management Network Commercial	$1,691.50
Rate for Payer: Humana Medicare	$616.90
Rate for Payer: Kaiser Permanente Commercial	$1,791.00
Rate for Payer: Kaiser Permanente Medicaid	$1,014.90
Rate for Payer: Kaiser Permanente Medicare	$616.90
Rate for Payer: MDX Hawaii PPO	$1,930.30
Rate for Payer: Ohana Health Plan Medicaid	$616.90
Rate for Payer: Ohana Health Plan Medicare	$616.90
Rate for Payer: UnitedHealthcare Medicare	$616.90
Rate for Payer: University Health Alliance Commercial	$1,114.40

LFITV40 FH 22.2MM 6260-9-122

Facility

$1,990.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,114.40
Max. Negotiated Rate	$1,930.30
Rate for Payer: Cash Price	$1,194.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,393.00
Rate for Payer: Health Management Network Commercial	$1,691.50
Rate for Payer: Kaiser Permanente Commercial	$1,791.00
Rate for Payer: MDX Hawaii PPO	$1,930.30
Rate for Payer: University Health Alliance Commercial	$1,114.40

LG KNEE CRYO CUFF ONLY 11B01

Facility

$167.00

Hospital Revenue Code	272
Min. Negotiated Rate	$51.77
Max. Negotiated Rate	$161.99
Rate for Payer: AlohaCare Medicaid	$83.50
Rate for Payer: AlohaCare Medicare	$51.77
Rate for Payer: Cash Price	$100.20
Rate for Payer: Devoted Health Medicare	$56.78
Rate for Payer: Hawaii Medical Service Association Medicare	$51.77
Rate for Payer: Hawaii Western Management Group Commercial	$158.65
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Humana Medicare	$51.77
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: Kaiser Permanente Medicaid	$85.17
Rate for Payer: Kaiser Permanente Medicare	$51.77
Rate for Payer: MDX Hawaii PPO	$161.99
Rate for Payer: Ohana Health Plan Medicaid	$51.77
Rate for Payer: Ohana Health Plan Medicare	$51.77
Rate for Payer: UnitedHealthcare Medicare	$51.77
Rate for Payer: University Health Alliance Commercial	$121.73

LG KNEE CRYO CUFF ONLY 11B01

Facility

$167.00

Hospital Revenue Code	272
Min. Negotiated Rate	$141.95
Max. Negotiated Rate	$161.99
Rate for Payer: Cash Price	$100.20
Rate for Payer: Health Management Network Commercial	$141.95
Rate for Payer: Kaiser Permanente Commercial	$150.30
Rate for Payer: MDX Hawaii PPO	$161.99

L HOOK ELECTRODE E3773-36C

Facility

$174.00

Hospital Revenue Code	272
Min. Negotiated Rate	$53.94
Max. Negotiated Rate	$168.78
Rate for Payer: AlohaCare Medicaid	$87.00
Rate for Payer: AlohaCare Medicare	$53.94
Rate for Payer: Cash Price	$104.40
Rate for Payer: Devoted Health Medicare	$59.16
Rate for Payer: Hawaii Medical Service Association Medicare	$53.94
Rate for Payer: Hawaii Western Management Group Commercial	$165.30
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Humana Medicare	$53.94
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: Kaiser Permanente Medicaid	$88.74
Rate for Payer: Kaiser Permanente Medicare	$53.94
Rate for Payer: MDX Hawaii PPO	$168.78
Rate for Payer: Ohana Health Plan Medicaid	$53.94
Rate for Payer: Ohana Health Plan Medicare	$53.94
Rate for Payer: UnitedHealthcare Medicare	$53.94
Rate for Payer: University Health Alliance Commercial	$126.83

L HOOK ELECTRODE E3773-36C

Facility

$174.00

Hospital Revenue Code	272
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$104.40
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: MDX Hawaii PPO	$168.78

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$34.00

Service Code	NDC 00409317803
Hospital Revenue Code	250
Min. Negotiated Rate	$28.90
Max. Negotiated Rate	$32.98
Rate for Payer: Cash Price	$20.40
Rate for Payer: Health Management Network Commercial	$28.90
Rate for Payer: Kaiser Permanente Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$32.98

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$11.00

Service Code	NDC 00409000710
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

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$55.00

Service Code	NDC 63323048257
Hospital Revenue Code	250
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$24.00

Service Code	NDC 63323048227
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

Know your out-of-pocket cost for care.

All Charges