Kau Hospital

All Charges

Charge

Type

Setting

Price

LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [184179]

Facility

$445.00

Service Code	NDC 69488001061
Hospital Revenue Code	343
Min. Negotiated Rate	$378.25
Max. Negotiated Rate	$431.65
Rate for Payer: Cash Price	$267.00
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Kaiser Permanente Commercial	$400.50
Rate for Payer: MDX Hawaii PPO	$431.65

LUTETIUM LU-177 VIPIVOTIDE TETRAXETAN 27 MCI/ML (1,000 MBQ/ML) IV SOLN [184179]

Facility

$445.00

Service Code	NDC 69488001061
Hospital Revenue Code	343
Min. Negotiated Rate	$137.95
Max. Negotiated Rate	$431.65
Rate for Payer: AlohaCare Medicaid	$222.50
Rate for Payer: AlohaCare Medicare	$137.95
Rate for Payer: Cash Price	$267.00
Rate for Payer: Devoted Health Medicare	$151.30
Rate for Payer: Hawaii Medical Service Association Medicare	$137.95
Rate for Payer: Hawaii Western Management Group Commercial	$422.75
Rate for Payer: Health Management Network Commercial	$378.25
Rate for Payer: Humana Medicare	$137.95
Rate for Payer: Kaiser Permanente Commercial	$400.50
Rate for Payer: Kaiser Permanente Medicaid	$226.95
Rate for Payer: Kaiser Permanente Medicare	$137.95
Rate for Payer: MDX Hawaii PPO	$431.65
Rate for Payer: Ohana Health Plan Medicaid	$137.95
Rate for Payer: Ohana Health Plan Medicare	$137.95
Rate for Payer: UnitedHealthcare Medicare	$137.95
Rate for Payer: University Health Alliance Commercial	$324.36

LUTONIX 018 DCB 5X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$4,165.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: MDX Hawaii PPO	$4,753.00

LUTONIX 018 DCB 5X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,519.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: AlohaCare Medicaid	$2,450.00
Rate for Payer: AlohaCare Medicare	$1,519.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Devoted Health Medicare	$1,666.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,519.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,655.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: Humana Medicare	$1,519.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$2,499.00
Rate for Payer: Kaiser Permanente Medicare	$1,519.00
Rate for Payer: MDX Hawaii PPO	$4,753.00
Rate for Payer: Ohana Health Plan Medicaid	$1,519.00
Rate for Payer: Ohana Health Plan Medicare	$1,519.00
Rate for Payer: UnitedHealthcare Medicare	$1,519.00
Rate for Payer: University Health Alliance Commercial	$3,571.61

LUTONIX 018 DCB 6X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,519.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: AlohaCare Medicaid	$2,450.00
Rate for Payer: AlohaCare Medicare	$1,519.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Devoted Health Medicare	$1,666.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,519.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,655.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: Humana Medicare	$1,519.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: Kaiser Permanente Medicaid	$2,499.00
Rate for Payer: Kaiser Permanente Medicare	$1,519.00
Rate for Payer: MDX Hawaii PPO	$4,753.00
Rate for Payer: Ohana Health Plan Medicaid	$1,519.00
Rate for Payer: Ohana Health Plan Medicare	$1,519.00
Rate for Payer: UnitedHealthcare Medicare	$1,519.00
Rate for Payer: University Health Alliance Commercial	$3,571.61

LUTONIX 018 DCB 6X300

Facility

$4,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$4,165.00
Max. Negotiated Rate	$4,753.00
Rate for Payer: Cash Price	$2,940.00
Rate for Payer: Health Management Network Commercial	$4,165.00
Rate for Payer: Kaiser Permanente Commercial	$4,410.00
Rate for Payer: MDX Hawaii PPO	$4,753.00

LUTONIX 035 DCB 6X80

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,209.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$1,209.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$1,326.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,209.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$1,209.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$1,209.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$1,209.00
Rate for Payer: Ohana Health Plan Medicare	$1,209.00
Rate for Payer: UnitedHealthcare Medicare	$1,209.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB 6X80

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB 7X80

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,805.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: MDX Hawaii PPO	$3,201.00

LUTONIX 035 DCB 7X80

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,023.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: AlohaCare Medicaid	$1,650.00
Rate for Payer: AlohaCare Medicare	$1,023.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Devoted Health Medicare	$1,122.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,023.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,135.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Humana Medicare	$1,023.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: Kaiser Permanente Medicare	$1,023.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: Ohana Health Plan Medicaid	$1,023.00
Rate for Payer: Ohana Health Plan Medicare	$1,023.00
Rate for Payer: UnitedHealthcare Medicare	$1,023.00
Rate for Payer: University Health Alliance Commercial	$2,405.37

LUTONIX 035 DCB OTW 10X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,209.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$1,209.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$1,326.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,209.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$1,209.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$1,209.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$1,209.00
Rate for Payer: Ohana Health Plan Medicare	$1,209.00
Rate for Payer: UnitedHealthcare Medicare	$1,209.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 10X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 12X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,209.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$1,209.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$1,326.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,209.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$1,209.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$1,209.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$1,209.00
Rate for Payer: Ohana Health Plan Medicare	$1,209.00
Rate for Payer: UnitedHealthcare Medicare	$1,209.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 12X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 7X40

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,023.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: AlohaCare Medicaid	$1,650.00
Rate for Payer: AlohaCare Medicare	$1,023.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Devoted Health Medicare	$1,122.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,023.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,135.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Humana Medicare	$1,023.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: Kaiser Permanente Medicare	$1,023.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: Ohana Health Plan Medicaid	$1,023.00
Rate for Payer: Ohana Health Plan Medicare	$1,023.00
Rate for Payer: UnitedHealthcare Medicare	$1,023.00
Rate for Payer: University Health Alliance Commercial	$2,405.37

LUTONIX 035 DCB OTW 7X40

Facility

$3,300.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$2,805.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,970.00
Rate for Payer: MDX Hawaii PPO	$3,201.00

LUTONIX 035 DCB OTW 8X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 8X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,209.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$1,209.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$1,326.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,209.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$1,209.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$1,209.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$1,209.00
Rate for Payer: Ohana Health Plan Medicare	$1,209.00
Rate for Payer: UnitedHealthcare Medicare	$1,209.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LUTONIX 035 DCB OTW 9X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: MDX Hawaii PPO	$3,783.00

LUTONIX 035 DCB OTW 9X40

Facility

$3,900.00

Service Code	HCPCS C2623
Hospital Revenue Code	272
Min. Negotiated Rate	$1,209.00
Max. Negotiated Rate	$3,783.00
Rate for Payer: AlohaCare Medicaid	$1,950.00
Rate for Payer: AlohaCare Medicare	$1,209.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Devoted Health Medicare	$1,326.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,209.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,705.00
Rate for Payer: Health Management Network Commercial	$3,315.00
Rate for Payer: Humana Medicare	$1,209.00
Rate for Payer: Kaiser Permanente Commercial	$3,510.00
Rate for Payer: Kaiser Permanente Medicaid	$1,989.00
Rate for Payer: Kaiser Permanente Medicare	$1,209.00
Rate for Payer: MDX Hawaii PPO	$3,783.00
Rate for Payer: Ohana Health Plan Medicaid	$1,209.00
Rate for Payer: Ohana Health Plan Medicare	$1,209.00
Rate for Payer: UnitedHealthcare Medicare	$1,209.00
Rate for Payer: University Health Alliance Commercial	$2,842.71

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$76,510.06

Service Code	MSDRG 821
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$76,510.06

Service Code	MSDRG 820
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$30,646.69

Service Code	MSDRG 822
Min. Negotiated Rate	$30,646.69
Max. Negotiated Rate	$30,646.69
Rate for Payer: Hawaii Medical Service Association Commercial	$30,646.69

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$77,718.86

Service Code	MSDRG 841
Min. Negotiated Rate	$77,718.86
Max. Negotiated Rate	$77,718.86
Rate for Payer: Hawaii Medical Service Association Commercial	$77,718.86

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$82,293.34

Service Code	MSDRG 840
Min. Negotiated Rate	$82,293.34
Max. Negotiated Rate	$82,293.34
Rate for Payer: Hawaii Medical Service Association Commercial	$82,293.34

Know your out-of-pocket cost for care.

All Charges