Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

KNEE SPLINT 20"

Facility

$4.00

Hospital Charge Code	8166
Hospital Revenue Code	270
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.60
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

KNEE SPLINT 20"

Facility

$4.00

Hospital Charge Code	8166
Hospital Revenue Code	270
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$1.68
Rate for Payer: Cash Price	$2.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$3.68
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.68
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$1.68
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$1.68
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$1.68
Rate for Payer: Ohana Health Plan Medicare	$1.68
Rate for Payer: UnitedHealthcare Medicare	$1.68
Rate for Payer: University Health Alliance Commercial	$2.92

KNEE SPLINT 24"

Facility

$12.00

Hospital Charge Code	8167
Hospital Revenue Code	270
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$5.04
Rate for Payer: Cash Price	$7.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.04
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Hawaii Medical Service Association Medicare	$5.04
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$5.04
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$5.04
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$5.04
Rate for Payer: Ohana Health Plan Medicare	$5.04
Rate for Payer: UnitedHealthcare Medicare	$5.04
Rate for Payer: University Health Alliance Commercial	$8.75

KNEE SPLINT 24"

Facility

$12.00

Hospital Charge Code	8167
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

labetalol 100 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 23155072301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

labetalol 100 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 23155072301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

labetalol 200 mg Tab UD [KMC]

Facility

$3.08

Service Code	NDC 00904592961
Hospital Revenue Code	250
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$2.99
Rate for Payer: Cash Price	$2.00
Rate for Payer: Health Management Network Commercial	$2.62
Rate for Payer: Kaiser Permanente Commercial	$2.77
Rate for Payer: MDX Hawaii PPO	$2.99

labetalol 200 mg Tab UD [KMC]

Facility

$3.08

Service Code	NDC 00904592961
Hospital Revenue Code	250
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$2.99
Rate for Payer: AlohaCare Medicaid	$1.54
Rate for Payer: AlohaCare Medicare	$1.29
Rate for Payer: Cash Price	$2.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.83
Rate for Payer: Devoted Health Medicare	$1.29
Rate for Payer: Hawaii Medical Service Association Medicare	$1.29
Rate for Payer: Hawaii Western Management Group Commercial	$2.93
Rate for Payer: Health Management Network Commercial	$2.62
Rate for Payer: Humana Medicare	$1.29
Rate for Payer: Kaiser Permanente Commercial	$2.77
Rate for Payer: Kaiser Permanente Medicaid	$1.57
Rate for Payer: Kaiser Permanente Medicare	$1.29
Rate for Payer: MDX Hawaii PPO	$2.99
Rate for Payer: Ohana Health Plan Medicaid	$1.29
Rate for Payer: Ohana Health Plan Medicare	$1.29
Rate for Payer: UnitedHealthcare Medicaid	$1.85
Rate for Payer: UnitedHealthcare Medicare	$1.29
Rate for Payer: University Health Alliance Commercial	$2.25

labetalol 5 mg/mL IV Sol [KMC]

Facility

$3.00

Service Code	NDC 51991093598
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

labetalol 5 mg/mL IV Sol [KMC]

Facility

$3.00

Service Code	NDC 51991093598
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

LACERATION TRAY

Facility

$6.00

Hospital Charge Code	8169
Hospital Revenue Code	272
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.82
Rate for Payer: AlohaCare Medicaid	$3.00
Rate for Payer: AlohaCare Medicare	$2.52
Rate for Payer: Cash Price	$3.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.52
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.52
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Humana Medicare	$2.52
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: Kaiser Permanente Medicare	$2.52
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: Ohana Health Plan Medicaid	$2.52
Rate for Payer: Ohana Health Plan Medicare	$2.52
Rate for Payer: UnitedHealthcare Medicare	$2.52
Rate for Payer: University Health Alliance Commercial	$4.37

LACERATION TRAY

Facility

$6.00

Hospital Charge Code	8169
Hospital Revenue Code	272
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.90
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$5.40
Rate for Payer: MDX Hawaii PPO	$5.82

LAC NECK/HANDS/FEET <2.5CM INT Charge

Facility

$1,017.00

Service Code	HCPCS 12041
Hospital Charge Code	440120410
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

LAC NECK/HANDS/FEET <2.5CM INT Charge

Facility

$1,017.00

Service Code	HCPCS 12041
Hospital Charge Code	440120410
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$508.50
Rate for Payer: AlohaCare Medicare	$427.14
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$935.64
Rate for Payer: Devoted Health Medicare	$427.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.14
Rate for Payer: Hawaii Western Management Group Commercial	$966.15
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$427.14
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.14
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$427.14
Rate for Payer: Ohana Health Plan Medicare	$427.14
Rate for Payer: UnitedHealthcare Medicare	$427.14
Rate for Payer: University Health Alliance Commercial	$741.29

LAC NECK/HANDS/FT 7.6-12.5 INT Charge

Facility

$1,017.00

Service Code	HCPCS 12044
Hospital Charge Code	440120440
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

LAC NECK/HANDS/FT 7.6-12.5 INT Charge

Facility

$1,017.00

Service Code	HCPCS 12044
Hospital Charge Code	440120440
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$508.50
Rate for Payer: AlohaCare Medicare	$427.14
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$935.64
Rate for Payer: Devoted Health Medicare	$427.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.14
Rate for Payer: Hawaii Western Management Group Commercial	$966.15
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$427.14
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.14
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$427.14
Rate for Payer: Ohana Health Plan Medicare	$427.14
Rate for Payer: UnitedHealthcare Medicare	$427.14
Rate for Payer: University Health Alliance Commercial	$741.29

lacosamide 100 mg Tab [KMC]

Facility

$71.87

Service Code	NDC 16714054901
Hospital Revenue Code	250
Min. Negotiated Rate	$61.09
Max. Negotiated Rate	$69.71
Rate for Payer: Cash Price	$46.72
Rate for Payer: Health Management Network Commercial	$61.09
Rate for Payer: Kaiser Permanente Commercial	$64.68
Rate for Payer: MDX Hawaii PPO	$69.71

lacosamide 100 mg Tab [KMC]

Facility

$71.87

Service Code	NDC 16714054901
Hospital Revenue Code	250
Min. Negotiated Rate	$30.19
Max. Negotiated Rate	$69.71
Rate for Payer: AlohaCare Medicaid	$35.94
Rate for Payer: AlohaCare Medicare	$30.19
Rate for Payer: Cash Price	$46.72
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$66.12
Rate for Payer: Devoted Health Medicare	$30.19
Rate for Payer: Hawaii Medical Service Association Medicare	$30.19
Rate for Payer: Hawaii Western Management Group Commercial	$68.28
Rate for Payer: Health Management Network Commercial	$61.09
Rate for Payer: Humana Medicare	$30.19
Rate for Payer: Kaiser Permanente Commercial	$64.68
Rate for Payer: Kaiser Permanente Medicaid	$36.65
Rate for Payer: Kaiser Permanente Medicare	$30.19
Rate for Payer: MDX Hawaii PPO	$69.71
Rate for Payer: Ohana Health Plan Medicaid	$30.19
Rate for Payer: Ohana Health Plan Medicare	$30.19
Rate for Payer: UnitedHealthcare Medicaid	$43.12
Rate for Payer: UnitedHealthcare Medicare	$30.19
Rate for Payer: University Health Alliance Commercial	$52.39

lacosamide 150 mg Tab [KMC]

Facility

$76.12

Service Code	NDC 16714055001
Hospital Revenue Code	250
Min. Negotiated Rate	$31.97
Max. Negotiated Rate	$73.84
Rate for Payer: AlohaCare Medicaid	$38.06
Rate for Payer: AlohaCare Medicare	$31.97
Rate for Payer: Cash Price	$49.48
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$70.03
Rate for Payer: Devoted Health Medicare	$31.97
Rate for Payer: Hawaii Medical Service Association Medicare	$31.97
Rate for Payer: Hawaii Western Management Group Commercial	$72.31
Rate for Payer: Health Management Network Commercial	$64.70
Rate for Payer: Humana Medicare	$31.97
Rate for Payer: Kaiser Permanente Commercial	$68.51
Rate for Payer: Kaiser Permanente Medicaid	$38.82
Rate for Payer: Kaiser Permanente Medicare	$31.97
Rate for Payer: MDX Hawaii PPO	$73.84
Rate for Payer: Ohana Health Plan Medicaid	$31.97
Rate for Payer: Ohana Health Plan Medicare	$31.97
Rate for Payer: UnitedHealthcare Medicaid	$45.67
Rate for Payer: UnitedHealthcare Medicare	$31.97
Rate for Payer: University Health Alliance Commercial	$55.48

lacosamide 150 mg Tab [KMC]

Facility

$76.12

Service Code	NDC 16714055001
Hospital Revenue Code	250
Min. Negotiated Rate	$64.70
Max. Negotiated Rate	$73.84
Rate for Payer: Cash Price	$49.48
Rate for Payer: Health Management Network Commercial	$64.70
Rate for Payer: Kaiser Permanente Commercial	$68.51
Rate for Payer: MDX Hawaii PPO	$73.84

lacosamide 200 mg Tab [KMC]

Facility

$71.23

Service Code	NDC 50228019560
Hospital Revenue Code	250
Min. Negotiated Rate	$60.55
Max. Negotiated Rate	$69.09
Rate for Payer: Cash Price	$46.30
Rate for Payer: Health Management Network Commercial	$60.55
Rate for Payer: Kaiser Permanente Commercial	$64.11
Rate for Payer: MDX Hawaii PPO	$69.09

lacosamide 200 mg Tab [KMC]

Facility

$71.23

Service Code	NDC 50228019560
Hospital Revenue Code	250
Min. Negotiated Rate	$29.92
Max. Negotiated Rate	$69.09
Rate for Payer: AlohaCare Medicaid	$35.62
Rate for Payer: AlohaCare Medicare	$29.92
Rate for Payer: Cash Price	$46.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$65.53
Rate for Payer: Devoted Health Medicare	$29.92
Rate for Payer: Hawaii Medical Service Association Medicare	$29.92
Rate for Payer: Hawaii Western Management Group Commercial	$67.67
Rate for Payer: Health Management Network Commercial	$60.55
Rate for Payer: Humana Medicare	$29.92
Rate for Payer: Kaiser Permanente Commercial	$64.11
Rate for Payer: Kaiser Permanente Medicaid	$36.33
Rate for Payer: Kaiser Permanente Medicare	$29.92
Rate for Payer: MDX Hawaii PPO	$69.09
Rate for Payer: Ohana Health Plan Medicaid	$29.92
Rate for Payer: Ohana Health Plan Medicare	$29.92
Rate for Payer: UnitedHealthcare Medicaid	$42.74
Rate for Payer: UnitedHealthcare Medicare	$29.92
Rate for Payer: University Health Alliance Commercial	$51.92

lacosamide 50 mg Tab [KMC]

Facility

$32.22

Service Code	NDC 00131247735
Hospital Revenue Code	250
Min. Negotiated Rate	$27.39
Max. Negotiated Rate	$31.25
Rate for Payer: Cash Price	$20.94
Rate for Payer: Health Management Network Commercial	$27.39
Rate for Payer: Kaiser Permanente Commercial	$29.00
Rate for Payer: MDX Hawaii PPO	$31.25

lacosamide 50 mg Tab [KMC]

Facility

$32.22

Service Code	NDC 00131247735
Hospital Revenue Code	250
Min. Negotiated Rate	$13.53
Max. Negotiated Rate	$31.25
Rate for Payer: AlohaCare Medicaid	$16.11
Rate for Payer: AlohaCare Medicare	$13.53
Rate for Payer: Cash Price	$20.94
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$29.64
Rate for Payer: Devoted Health Medicare	$13.53
Rate for Payer: Hawaii Medical Service Association Medicare	$13.53
Rate for Payer: Hawaii Western Management Group Commercial	$30.61
Rate for Payer: Health Management Network Commercial	$27.39
Rate for Payer: Humana Medicare	$13.53
Rate for Payer: Kaiser Permanente Commercial	$29.00
Rate for Payer: Kaiser Permanente Medicaid	$16.43
Rate for Payer: Kaiser Permanente Medicare	$13.53
Rate for Payer: MDX Hawaii PPO	$31.25
Rate for Payer: Ohana Health Plan Medicaid	$13.53
Rate for Payer: Ohana Health Plan Medicare	$13.53
Rate for Payer: UnitedHealthcare Medicaid	$19.33
Rate for Payer: UnitedHealthcare Medicare	$13.53
Rate for Payer: University Health Alliance Commercial	$23.49

LAC SCALP/ARMS/LGS 1.1-2.5 COM Charge

Facility

$1,017.00

Service Code	HCPCS 13120
Hospital Charge Code	440131200
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

Know your out-of-pocket cost for care.

All Charges