Kohala Hospital

All Charges

Charge

Type

Setting

Price

LORAZEPAM 0.5 MG PO TABLET

Facility

$3.55

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$3.44
Rate for Payer: Cash Price	$2.31
Rate for Payer: Health Management Network Commercial	$3.02
Rate for Payer: Kaiser Permanente Commercial	$3.19
Rate for Payer: MDX Hawaii PPO	$3.44

LORAZEPAM 0.5 MG PO TABLET

Facility

$3.55

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$3.51
Rate for Payer: AlohaCare Medicaid	$1.77
Rate for Payer: AlohaCare Medicare	$3.19
Rate for Payer: Cash Price	$2.31
Rate for Payer: Devoted Health Medicare	$3.51
Rate for Payer: Hawaii Medical Service Association Medicare	$3.19
Rate for Payer: Hawaii Western Management Group Commercial	$3.37
Rate for Payer: Health Management Network Commercial	$3.02
Rate for Payer: Humana Medicare	$3.19
Rate for Payer: Kaiser Permanente Commercial	$3.19
Rate for Payer: Kaiser Permanente Medicaid	$1.81
Rate for Payer: Kaiser Permanente Medicare	$3.19
Rate for Payer: MDX Hawaii PPO	$3.44
Rate for Payer: Ohana Health Plan Medicaid	$3.19
Rate for Payer: Ohana Health Plan Medicare	$3.19
Rate for Payer: UnitedHealthcare Medicare	$3.19
Rate for Payer: University Health Alliance Commercial	$2.59

LORAZEPAM 1 MG IV (FOR CIWA AR SCORE)

Facility

$19.81

Service Code	HCPCS J2060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$19.61
Rate for Payer: AlohaCare Medicaid	$9.90
Rate for Payer: AlohaCare Medicare	$17.83
Rate for Payer: Cash Price	$12.88
Rate for Payer: Cash Price	$12.88
Rate for Payer: Devoted Health Medicare	$19.61
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$18.82
Rate for Payer: Health Management Network Commercial	$16.84
Rate for Payer: Humana Medicare	$17.83
Rate for Payer: Kaiser Permanente Commercial	$17.83
Rate for Payer: Kaiser Permanente Medicaid	$10.10
Rate for Payer: Kaiser Permanente Medicare	$17.83
Rate for Payer: MDX Hawaii PPO	$19.22
Rate for Payer: Ohana Health Plan Medicaid	$17.83
Rate for Payer: Ohana Health Plan Medicare	$17.83
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: UnitedHealthcare Medicare	$17.83
Rate for Payer: University Health Alliance Commercial	$14.44

LORAZEPAM 1 MG IV (FOR CIWA AR SCORE)

Facility

$19.81

Service Code	HCPCS J2060
Hospital Revenue Code	250
Min. Negotiated Rate	$16.84
Max. Negotiated Rate	$19.22
Rate for Payer: Cash Price	$12.88
Rate for Payer: Health Management Network Commercial	$16.84
Rate for Payer: Kaiser Permanente Commercial	$17.83
Rate for Payer: MDX Hawaii PPO	$19.22

LORAZEPAM 1 MG PO TABLET

Facility

$4.63

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$4.58
Rate for Payer: AlohaCare Medicaid	$2.31
Rate for Payer: AlohaCare Medicare	$4.17
Rate for Payer: Cash Price	$3.01
Rate for Payer: Devoted Health Medicare	$4.58
Rate for Payer: Hawaii Medical Service Association Medicare	$4.17
Rate for Payer: Hawaii Western Management Group Commercial	$4.40
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Humana Medicare	$4.17
Rate for Payer: Kaiser Permanente Commercial	$4.17
Rate for Payer: Kaiser Permanente Medicaid	$2.36
Rate for Payer: Kaiser Permanente Medicare	$4.17
Rate for Payer: MDX Hawaii PPO	$4.49
Rate for Payer: Ohana Health Plan Medicaid	$4.17
Rate for Payer: Ohana Health Plan Medicare	$4.17
Rate for Payer: UnitedHealthcare Medicare	$4.17
Rate for Payer: University Health Alliance Commercial	$3.37

LORAZEPAM 1 MG PO TABLET

Facility

$4.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$4.49
Rate for Payer: Cash Price	$3.01
Rate for Payer: Health Management Network Commercial	$3.94
Rate for Payer: Kaiser Permanente Commercial	$4.17
Rate for Payer: MDX Hawaii PPO	$4.49

LORAZEPAM 2 MG IV PRN (FOR CIWA AR SCORE)

Facility

$19.81

Service Code	HCPCS J2060
Hospital Revenue Code	250
Min. Negotiated Rate	$16.84
Max. Negotiated Rate	$19.22
Rate for Payer: Cash Price	$12.88
Rate for Payer: Health Management Network Commercial	$16.84
Rate for Payer: Kaiser Permanente Commercial	$17.83
Rate for Payer: MDX Hawaii PPO	$19.22

LORAZEPAM 2 MG IV PRN (FOR CIWA AR SCORE)

Facility

$19.81

Service Code	HCPCS J2060
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$19.61
Rate for Payer: AlohaCare Medicaid	$9.90
Rate for Payer: AlohaCare Medicare	$17.83
Rate for Payer: Cash Price	$12.88
Rate for Payer: Cash Price	$12.88
Rate for Payer: Devoted Health Medicare	$19.61
Rate for Payer: Hawaii Medical Service Association ABD	$1.32
Rate for Payer: Hawaii Medical Service Association Medicare	$17.83
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.32
Rate for Payer: Hawaii Western Management Group Commercial	$18.82
Rate for Payer: Health Management Network Commercial	$16.84
Rate for Payer: Humana Medicare	$17.83
Rate for Payer: Kaiser Permanente Commercial	$17.83
Rate for Payer: Kaiser Permanente Medicaid	$10.10
Rate for Payer: Kaiser Permanente Medicare	$17.83
Rate for Payer: MDX Hawaii PPO	$19.22
Rate for Payer: Ohana Health Plan Medicaid	$17.83
Rate for Payer: Ohana Health Plan Medicare	$17.83
Rate for Payer: UnitedHealthcare Medicaid	$11.89
Rate for Payer: UnitedHealthcare Medicare	$17.83
Rate for Payer: University Health Alliance Commercial	$14.44

LOSARTAN 25 MG PO TABLET

Facility

$9.27

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$8.99
Rate for Payer: Cash Price	$6.03
Rate for Payer: Health Management Network Commercial	$7.88
Rate for Payer: Kaiser Permanente Commercial	$8.34
Rate for Payer: MDX Hawaii PPO	$8.99

LOSARTAN 25 MG PO TABLET

Facility

$9.27

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$9.18
Rate for Payer: AlohaCare Medicaid	$4.63
Rate for Payer: AlohaCare Medicare	$8.34
Rate for Payer: Cash Price	$6.03
Rate for Payer: Devoted Health Medicare	$9.18
Rate for Payer: Hawaii Medical Service Association Medicare	$8.34
Rate for Payer: Hawaii Western Management Group Commercial	$8.81
Rate for Payer: Health Management Network Commercial	$7.88
Rate for Payer: Humana Medicare	$8.34
Rate for Payer: Kaiser Permanente Commercial	$8.34
Rate for Payer: Kaiser Permanente Medicaid	$4.73
Rate for Payer: Kaiser Permanente Medicare	$8.34
Rate for Payer: MDX Hawaii PPO	$8.99
Rate for Payer: Ohana Health Plan Medicaid	$8.34
Rate for Payer: Ohana Health Plan Medicare	$8.34
Rate for Payer: UnitedHealthcare Medicare	$8.34
Rate for Payer: University Health Alliance Commercial	$6.76

LOSARTAN 50 MG PO TABLET

Facility

$12.42

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$12.05
Rate for Payer: MDX Hawaii PPO	$3.62
Rate for Payer: MDX Hawaii PPO	$12.05
Rate for Payer: Cash Price	$8.07
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Management Network Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$3.17
Rate for Payer: Kaiser Permanente Commercial	$11.18
Rate for Payer: Kaiser Permanente Commercial	$3.36

LOSARTAN 50 MG PO TABLET

Facility

$3.73

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$3.69
Rate for Payer: AlohaCare Medicaid	$1.86
Rate for Payer: AlohaCare Medicaid	$6.21
Rate for Payer: AlohaCare Medicare	$11.18
Rate for Payer: AlohaCare Medicare	$3.36
Rate for Payer: Cash Price	$8.07
Rate for Payer: Cash Price	$2.42
Rate for Payer: Devoted Health Medicare	$3.69
Rate for Payer: Devoted Health Medicare	$12.30
Rate for Payer: Hawaii Medical Service Association Medicare	$11.18
Rate for Payer: Hawaii Medical Service Association Medicare	$3.36
Rate for Payer: Hawaii Western Management Group Commercial	$11.80
Rate for Payer: Hawaii Western Management Group Commercial	$3.54
Rate for Payer: Health Management Network Commercial	$3.17
Rate for Payer: Health Management Network Commercial	$10.56
Rate for Payer: Humana Medicare	$3.36
Rate for Payer: Humana Medicare	$11.18
Rate for Payer: Kaiser Permanente Commercial	$11.18
Rate for Payer: Kaiser Permanente Commercial	$3.36
Rate for Payer: Kaiser Permanente Medicaid	$1.90
Rate for Payer: Kaiser Permanente Medicaid	$6.33
Rate for Payer: Kaiser Permanente Medicare	$11.18
Rate for Payer: Kaiser Permanente Medicare	$3.36
Rate for Payer: MDX Hawaii PPO	$12.05
Rate for Payer: MDX Hawaii PPO	$3.62
Rate for Payer: Ohana Health Plan Medicaid	$11.18
Rate for Payer: Ohana Health Plan Medicaid	$3.36
Rate for Payer: Ohana Health Plan Medicare	$11.18
Rate for Payer: Ohana Health Plan Medicare	$3.36
Rate for Payer: UnitedHealthcare Medicare	$3.36
Rate for Payer: UnitedHealthcare Medicare	$11.18
Rate for Payer: University Health Alliance Commercial	$2.72
Rate for Payer: University Health Alliance Commercial	$9.05

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

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 40 MG PO TABLET

Facility

$174.63

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$87.31
Max. Negotiated Rate	$172.88
Rate for Payer: AlohaCare Medicaid	$87.31
Rate for Payer: AlohaCare Medicare	$157.17
Rate for Payer: Cash Price	$113.51
Rate for Payer: Devoted Health Medicare	$172.88
Rate for Payer: Hawaii Medical Service Association Medicare	$157.17
Rate for Payer: Hawaii Western Management Group Commercial	$165.90
Rate for Payer: Health Management Network Commercial	$148.44
Rate for Payer: Humana Medicare	$157.17
Rate for Payer: Kaiser Permanente Commercial	$157.17
Rate for Payer: Kaiser Permanente Medicaid	$89.06
Rate for Payer: Kaiser Permanente Medicare	$157.17
Rate for Payer: MDX Hawaii PPO	$169.39
Rate for Payer: Ohana Health Plan Medicaid	$157.17
Rate for Payer: Ohana Health Plan Medicare	$157.17
Rate for Payer: UnitedHealthcare Medicare	$157.17
Rate for Payer: University Health Alliance Commercial	$127.29

LURASIDONE 40 MG PO TABLET

Facility

$174.63

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$148.44
Max. Negotiated Rate	$169.39
Rate for Payer: Cash Price	$113.51
Rate for Payer: Health Management Network Commercial	$148.44
Rate for Payer: Kaiser Permanente Commercial	$157.17
Rate for Payer: MDX Hawaii PPO	$169.39

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

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$92,532.61

Service Code	MSDRG 824
Min. Negotiated Rate	$92,532.61
Max. Negotiated Rate	$92,532.61
Rate for Payer: Hawaii Medical Service Association Commercial	$92,532.61

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$92,532.61

Service Code	MSDRG 823
Min. Negotiated Rate	$92,532.61
Max. Negotiated Rate	$92,532.61
Rate for Payer: Hawaii Medical Service Association Commercial	$92,532.61

Know your out-of-pocket cost for care.

All Charges