Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

Lactic Acid

Facility

$109.00

Service Code	HCPCS 83605
Hospital Charge Code	422836050
Hospital Revenue Code	301
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

Lactic Acid

Facility

$109.00

Service Code	HCPCS 83605
Hospital Charge Code	422836050
Hospital Revenue Code	301
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$45.78
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$100.28
Rate for Payer: Devoted Health Medicare	$45.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$45.78
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$45.78
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$45.78
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$45.78
Rate for Payer: Ohana Health Plan Medicare	$45.78
Rate for Payer: UnitedHealthcare Medicaid	$14.76
Rate for Payer: UnitedHealthcare Medicare	$45.78
Rate for Payer: University Health Alliance Commercial	$27.60

Lactic Acid 2

Facility

$109.00

Service Code	HCPCS 83605
Hospital Charge Code	422836050
Hospital Revenue Code	301
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$45.78
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$100.28
Rate for Payer: Devoted Health Medicare	$45.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$45.78
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$45.78
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$45.78
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$45.78
Rate for Payer: Ohana Health Plan Medicare	$45.78
Rate for Payer: UnitedHealthcare Medicaid	$14.76
Rate for Payer: UnitedHealthcare Medicare	$45.78
Rate for Payer: University Health Alliance Commercial	$27.60

Lactic Acid 2

Facility

$109.00

Service Code	HCPCS 83605
Hospital Charge Code	422836050
Hospital Revenue Code	301
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

Lactic Acid DLS

Facility

$109.00

Service Code	HCPCS 83605
Hospital Charge Code	422836055
Hospital Revenue Code	301
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$45.78
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$100.28
Rate for Payer: Devoted Health Medicare	$45.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$45.78
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$45.78
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$45.78
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$45.78
Rate for Payer: Ohana Health Plan Medicare	$45.78
Rate for Payer: UnitedHealthcare Medicaid	$14.76
Rate for Payer: UnitedHealthcare Medicare	$45.78
Rate for Payer: University Health Alliance Commercial	$27.60

Lactic Acid DLS

Facility

$109.00

Service Code	HCPCS 83605
Hospital Charge Code	422836055
Hospital Revenue Code	301
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

lactobacillus acidophilus 75 mil units Cap [KMC]

Facility

$3.00

Service Code	NDC 00904421360
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

lactobacillus acidophilus 75 mil units Cap [KMC]

Facility

$3.00

Service Code	NDC 00904421360
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

lactobacillus rhamnosus GG 80 mg oral capsule [KMC]

Facility

$3.00

Service Code	NDC 49100036374
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

lactobacillus rhamnosus GG 80 mg oral capsule [KMC]

Facility

$3.00

Service Code	NDC 49100036374
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

lactulose 20 g/30 mL solution [KMC]

Facility

$0.26

Service Code	NDC 00116400530
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.25
Rate for Payer: AlohaCare Medicaid	$0.13
Rate for Payer: AlohaCare Medicare	$0.11
Rate for Payer: Cash Price	$0.17
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.24
Rate for Payer: Devoted Health Medicare	$0.11
Rate for Payer: Hawaii Medical Service Association Medicare	$0.11
Rate for Payer: Hawaii Western Management Group Commercial	$0.25
Rate for Payer: Health Management Network Commercial	$0.22
Rate for Payer: Humana Medicare	$0.11
Rate for Payer: Kaiser Permanente Commercial	$0.23
Rate for Payer: Kaiser Permanente Medicaid	$0.13
Rate for Payer: Kaiser Permanente Medicare	$0.11
Rate for Payer: MDX Hawaii PPO	$0.25
Rate for Payer: Ohana Health Plan Medicaid	$0.11
Rate for Payer: Ohana Health Plan Medicare	$0.11
Rate for Payer: UnitedHealthcare Medicaid	$0.16
Rate for Payer: UnitedHealthcare Medicare	$0.11
Rate for Payer: University Health Alliance Commercial	$0.19

lactulose 20 g/30 mL solution [KMC]

Facility

$0.26

Service Code	NDC 00116400530
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: Health Management Network Commercial	$0.22
Rate for Payer: Kaiser Permanente Commercial	$0.23
Rate for Payer: MDX Hawaii PPO	$0.25

LAIV4 VACCINE FOR INTRANASAL USE

Professional

Both

$0.01

Service Code	HCPCS 90672 SL
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$25.46
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$25.46
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

lamiVUDine 100 mg Tab [KMC]

Facility

$64.44

Service Code	NDC 60505325006
Hospital Revenue Code	250
Min. Negotiated Rate	$27.06
Max. Negotiated Rate	$62.51
Rate for Payer: AlohaCare Medicaid	$32.22
Rate for Payer: AlohaCare Medicare	$27.06
Rate for Payer: Cash Price	$41.89
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$59.28
Rate for Payer: Devoted Health Medicare	$27.06
Rate for Payer: Hawaii Medical Service Association Medicare	$27.06
Rate for Payer: Hawaii Western Management Group Commercial	$61.22
Rate for Payer: Health Management Network Commercial	$54.77
Rate for Payer: Humana Medicare	$27.06
Rate for Payer: Kaiser Permanente Commercial	$58.00
Rate for Payer: Kaiser Permanente Medicaid	$32.86
Rate for Payer: Kaiser Permanente Medicare	$27.06
Rate for Payer: MDX Hawaii PPO	$62.51
Rate for Payer: Ohana Health Plan Medicaid	$27.06
Rate for Payer: Ohana Health Plan Medicare	$27.06
Rate for Payer: UnitedHealthcare Medicaid	$38.66
Rate for Payer: UnitedHealthcare Medicare	$27.06
Rate for Payer: University Health Alliance Commercial	$46.97

lamiVUDine 100 mg Tab [KMC]

Facility

$64.44

Service Code	NDC 60505325006
Hospital Revenue Code	250
Min. Negotiated Rate	$54.77
Max. Negotiated Rate	$62.51
Rate for Payer: Cash Price	$41.89
Rate for Payer: Health Management Network Commercial	$54.77
Rate for Payer: Kaiser Permanente Commercial	$58.00
Rate for Payer: MDX Hawaii PPO	$62.51

lamiVUDine 150 mg Tab

Facility

$28.61

Service Code	NDC 64380071003
Hospital Revenue Code	250
Min. Negotiated Rate	$24.32
Max. Negotiated Rate	$27.75
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$24.32
Rate for Payer: Kaiser Permanente Commercial	$25.75
Rate for Payer: MDX Hawaii PPO	$27.75

lamiVUDine 150 mg Tab

Facility

$28.61

Service Code	NDC 64380071003
Hospital Revenue Code	250
Min. Negotiated Rate	$12.02
Max. Negotiated Rate	$27.75
Rate for Payer: AlohaCare Medicaid	$14.30
Rate for Payer: AlohaCare Medicare	$12.02
Rate for Payer: Cash Price	$18.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$26.32
Rate for Payer: Devoted Health Medicare	$12.02
Rate for Payer: Hawaii Medical Service Association Medicare	$12.02
Rate for Payer: Hawaii Western Management Group Commercial	$27.18
Rate for Payer: Health Management Network Commercial	$24.32
Rate for Payer: Humana Medicare	$12.02
Rate for Payer: Kaiser Permanente Commercial	$25.75
Rate for Payer: Kaiser Permanente Medicaid	$14.59
Rate for Payer: Kaiser Permanente Medicare	$12.02
Rate for Payer: MDX Hawaii PPO	$27.75
Rate for Payer: Ohana Health Plan Medicaid	$12.02
Rate for Payer: Ohana Health Plan Medicare	$12.02
Rate for Payer: UnitedHealthcare Medicaid	$17.17
Rate for Payer: UnitedHealthcare Medicare	$12.02
Rate for Payer: University Health Alliance Commercial	$20.85

lamiVUDine 300 mg Tab [KMC]

Facility

$57.23

Service Code	NDC 64380071104
Hospital Revenue Code	250
Min. Negotiated Rate	$24.04
Max. Negotiated Rate	$55.51
Rate for Payer: AlohaCare Medicaid	$28.61
Rate for Payer: AlohaCare Medicare	$24.04
Rate for Payer: Cash Price	$37.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$52.65
Rate for Payer: Devoted Health Medicare	$24.04
Rate for Payer: Hawaii Medical Service Association Medicare	$24.04
Rate for Payer: Hawaii Western Management Group Commercial	$54.37
Rate for Payer: Health Management Network Commercial	$48.65
Rate for Payer: Humana Medicare	$24.04
Rate for Payer: Kaiser Permanente Commercial	$51.51
Rate for Payer: Kaiser Permanente Medicaid	$29.19
Rate for Payer: Kaiser Permanente Medicare	$24.04
Rate for Payer: MDX Hawaii PPO	$55.51
Rate for Payer: Ohana Health Plan Medicaid	$24.04
Rate for Payer: Ohana Health Plan Medicare	$24.04
Rate for Payer: UnitedHealthcare Medicaid	$34.34
Rate for Payer: UnitedHealthcare Medicare	$24.04
Rate for Payer: University Health Alliance Commercial	$41.71

lamiVUDine 300 mg Tab [KMC]

Facility

$57.23

Service Code	NDC 64380071104
Hospital Revenue Code	250
Min. Negotiated Rate	$48.65
Max. Negotiated Rate	$55.51
Rate for Payer: Cash Price	$37.20
Rate for Payer: Health Management Network Commercial	$48.65
Rate for Payer: Kaiser Permanente Commercial	$51.51
Rate for Payer: MDX Hawaii PPO	$55.51

lamiVUDine-zidovudine 150 mg-300 mg Tab [KMC]

Facility

$62.73

Service Code	NDC 49702020218
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$60.85
Rate for Payer: AlohaCare Medicaid	$31.36
Rate for Payer: AlohaCare Medicare	$26.35
Rate for Payer: Cash Price	$40.77
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$57.71
Rate for Payer: Devoted Health Medicare	$26.35
Rate for Payer: Hawaii Medical Service Association Medicare	$26.35
Rate for Payer: Hawaii Western Management Group Commercial	$59.59
Rate for Payer: Health Management Network Commercial	$53.32
Rate for Payer: Humana Medicare	$26.35
Rate for Payer: Kaiser Permanente Commercial	$56.46
Rate for Payer: Kaiser Permanente Medicaid	$31.99
Rate for Payer: Kaiser Permanente Medicare	$26.35
Rate for Payer: MDX Hawaii PPO	$60.85
Rate for Payer: Ohana Health Plan Medicaid	$26.35
Rate for Payer: Ohana Health Plan Medicare	$26.35
Rate for Payer: UnitedHealthcare Medicaid	$37.64
Rate for Payer: UnitedHealthcare Medicare	$26.35
Rate for Payer: University Health Alliance Commercial	$45.72

lamiVUDine-zidovudine 150 mg-300 mg Tab [KMC]

Facility

$62.73

Service Code	NDC 49702020218
Hospital Revenue Code	250
Min. Negotiated Rate	$53.32
Max. Negotiated Rate	$60.85
Rate for Payer: Cash Price	$40.77
Rate for Payer: Health Management Network Commercial	$53.32
Rate for Payer: Kaiser Permanente Commercial	$56.46
Rate for Payer: MDX Hawaii PPO	$60.85

lamoTRIgine 100 mg Tab [KMC]

Facility

$19.80

Service Code	NDC 16714019501
Hospital Revenue Code	250
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$19.21
Rate for Payer: AlohaCare Medicaid	$9.90
Rate for Payer: AlohaCare Medicare	$8.32
Rate for Payer: Cash Price	$12.87
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$18.22
Rate for Payer: Devoted Health Medicare	$8.32
Rate for Payer: Hawaii Medical Service Association Medicare	$8.32
Rate for Payer: Hawaii Western Management Group Commercial	$18.81
Rate for Payer: Health Management Network Commercial	$16.83
Rate for Payer: Humana Medicare	$8.32
Rate for Payer: Kaiser Permanente Commercial	$17.82
Rate for Payer: Kaiser Permanente Medicaid	$10.10
Rate for Payer: Kaiser Permanente Medicare	$8.32
Rate for Payer: MDX Hawaii PPO	$19.21
Rate for Payer: Ohana Health Plan Medicaid	$8.32
Rate for Payer: Ohana Health Plan Medicare	$8.32
Rate for Payer: UnitedHealthcare Medicaid	$11.88
Rate for Payer: UnitedHealthcare Medicare	$8.32
Rate for Payer: University Health Alliance Commercial	$14.43

lamoTRIgine 100 mg Tab [KMC]

Facility

$19.80

Service Code	NDC 16714019501
Hospital Revenue Code	250
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$19.21
Rate for Payer: Cash Price	$12.87
Rate for Payer: Health Management Network Commercial	$16.83
Rate for Payer: Kaiser Permanente Commercial	$17.82
Rate for Payer: MDX Hawaii PPO	$19.21

lamoTRIgine 25 mg Tab [KMC]

Facility

$16.64

Service Code	NDC 65862022701
Hospital Revenue Code	250
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$16.14
Rate for Payer: AlohaCare Medicaid	$8.32
Rate for Payer: AlohaCare Medicare	$6.99
Rate for Payer: Cash Price	$10.82
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.31
Rate for Payer: Devoted Health Medicare	$6.99
Rate for Payer: Hawaii Medical Service Association Medicare	$6.99
Rate for Payer: Hawaii Western Management Group Commercial	$15.81
Rate for Payer: Health Management Network Commercial	$14.14
Rate for Payer: Humana Medicare	$6.99
Rate for Payer: Kaiser Permanente Commercial	$14.98
Rate for Payer: Kaiser Permanente Medicaid	$8.49
Rate for Payer: Kaiser Permanente Medicare	$6.99
Rate for Payer: MDX Hawaii PPO	$16.14
Rate for Payer: Ohana Health Plan Medicaid	$6.99
Rate for Payer: Ohana Health Plan Medicare	$6.99
Rate for Payer: UnitedHealthcare Medicaid	$9.98
Rate for Payer: UnitedHealthcare Medicare	$6.99
Rate for Payer: University Health Alliance Commercial	$12.13

Know your out-of-pocket cost for care.

All Charges