Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

LET Gel 1.5ml topical [KMC]

Facility

$3.00

Service Code	NDC 00003084100
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

LET Gel 1.5ml topical [KMC]

Facility

$3.00

Service Code	NDC 00003084100
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

letrozole 2.5 mg Tab [KMC]

Facility

$72.46

Service Code	NDC 51991075990
Hospital Revenue Code	250
Min. Negotiated Rate	$61.59
Max. Negotiated Rate	$70.29
Rate for Payer: Cash Price	$47.10
Rate for Payer: Health Management Network Commercial	$61.59
Rate for Payer: Kaiser Permanente Commercial	$65.21
Rate for Payer: MDX Hawaii PPO	$70.29

letrozole 2.5 mg Tab [KMC]

Facility

$72.46

Service Code	NDC 51991075990
Hospital Revenue Code	250
Min. Negotiated Rate	$30.43
Max. Negotiated Rate	$70.29
Rate for Payer: AlohaCare Medicaid	$36.23
Rate for Payer: AlohaCare Medicare	$30.43
Rate for Payer: Cash Price	$47.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$66.66
Rate for Payer: Devoted Health Medicare	$30.43
Rate for Payer: Hawaii Medical Service Association Medicare	$30.43
Rate for Payer: Hawaii Western Management Group Commercial	$68.84
Rate for Payer: Health Management Network Commercial	$61.59
Rate for Payer: Humana Medicare	$30.43
Rate for Payer: Kaiser Permanente Commercial	$65.21
Rate for Payer: Kaiser Permanente Medicaid	$36.95
Rate for Payer: Kaiser Permanente Medicare	$30.43
Rate for Payer: MDX Hawaii PPO	$70.29
Rate for Payer: Ohana Health Plan Medicaid	$30.43
Rate for Payer: Ohana Health Plan Medicare	$30.43
Rate for Payer: UnitedHealthcare Medicaid	$43.48
Rate for Payer: UnitedHealthcare Medicare	$30.43
Rate for Payer: University Health Alliance Commercial	$52.82

leucovorin 5 mg Tab [KMC]

Facility

$6.74

Service Code	NDC 42806035830
Hospital Revenue Code	250
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$6.54
Rate for Payer: Cash Price	$4.38
Rate for Payer: Health Management Network Commercial	$5.73
Rate for Payer: Kaiser Permanente Commercial	$6.07
Rate for Payer: MDX Hawaii PPO	$6.54

leucovorin 5 mg Tab [KMC]

Facility

$6.74

Service Code	NDC 42806035830
Hospital Revenue Code	250
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$6.54
Rate for Payer: AlohaCare Medicaid	$3.37
Rate for Payer: AlohaCare Medicare	$2.83
Rate for Payer: Cash Price	$4.38
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6.20
Rate for Payer: Devoted Health Medicare	$2.83
Rate for Payer: Hawaii Medical Service Association Medicare	$2.83
Rate for Payer: Hawaii Western Management Group Commercial	$6.40
Rate for Payer: Health Management Network Commercial	$5.73
Rate for Payer: Humana Medicare	$2.83
Rate for Payer: Kaiser Permanente Commercial	$6.07
Rate for Payer: Kaiser Permanente Medicaid	$3.44
Rate for Payer: Kaiser Permanente Medicare	$2.83
Rate for Payer: MDX Hawaii PPO	$6.54
Rate for Payer: Ohana Health Plan Medicaid	$2.83
Rate for Payer: Ohana Health Plan Medicare	$2.83
Rate for Payer: UnitedHealthcare Medicaid	$4.04
Rate for Payer: UnitedHealthcare Medicare	$2.83
Rate for Payer: University Health Alliance Commercial	$4.91

leuprolide depot 7.5 mg/month Kit

Facility

$10,302.29

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$8,756.95
Max. Negotiated Rate	$9,993.22
Rate for Payer: Cash Price	$6,696.49
Rate for Payer: Health Management Network Commercial	$8,756.95
Rate for Payer: Kaiser Permanente Commercial	$9,272.06
Rate for Payer: MDX Hawaii PPO	$9,993.22

leuprolide depot 7.5 mg/month Kit

Facility

$10,302.29

Service Code	HCPCS J9217
Hospital Revenue Code	636
Min. Negotiated Rate	$155.42
Max. Negotiated Rate	$9,993.22
Rate for Payer: AlohaCare Medicaid	$5,151.15
Rate for Payer: AlohaCare Medicare	$4,326.96
Rate for Payer: Cash Price	$6,696.49
Rate for Payer: Cash Price	$6,696.49
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9,478.11
Rate for Payer: Devoted Health Medicare	$4,326.96
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$155.42
Rate for Payer: Hawaii Medical Service Association Commercial	$220.25
Rate for Payer: Hawaii Medical Service Association Medicare	$4,326.96
Rate for Payer: Hawaii Western Management Group Commercial	$9,787.18
Rate for Payer: Health Management Network Commercial	$8,756.95
Rate for Payer: Humana Medicare	$4,326.96
Rate for Payer: Kaiser Permanente Commercial	$9,272.06
Rate for Payer: Kaiser Permanente Medicaid	$5,254.17
Rate for Payer: Kaiser Permanente Medicare	$4,326.96
Rate for Payer: MDX Hawaii PPO	$9,993.22
Rate for Payer: Ohana Health Plan Medicaid	$4,326.96
Rate for Payer: Ohana Health Plan Medicare	$4,326.96
Rate for Payer: UnitedHealthcare Medicaid	$6,181.37
Rate for Payer: UnitedHealthcare Medicare	$4,326.96
Rate for Payer: University Health Alliance Commercial	$7,509.34

levalbuterol 0.63 mg/3 mL Inh Sol [KMC]

Facility

$8.94

Service Code	HCPCS J7614
Hospital Revenue Code	636
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$8.67
Rate for Payer: Cash Price	$5.81
Rate for Payer: Health Management Network Commercial	$7.60
Rate for Payer: Kaiser Permanente Commercial	$8.05
Rate for Payer: MDX Hawaii PPO	$8.67

levalbuterol 0.63 mg/3 mL Inh Sol [KMC]

Facility

$8.94

Service Code	HCPCS J7614
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$8.67
Rate for Payer: AlohaCare Medicaid	$4.47
Rate for Payer: AlohaCare Medicare	$3.75
Rate for Payer: Cash Price	$5.81
Rate for Payer: Cash Price	$5.81
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$8.22
Rate for Payer: Devoted Health Medicare	$3.75
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Medicare	$3.75
Rate for Payer: Hawaii Western Management Group Commercial	$8.49
Rate for Payer: Health Management Network Commercial	$7.60
Rate for Payer: Humana Medicare	$3.75
Rate for Payer: Kaiser Permanente Commercial	$8.05
Rate for Payer: Kaiser Permanente Medicaid	$4.56
Rate for Payer: Kaiser Permanente Medicare	$3.75
Rate for Payer: MDX Hawaii PPO	$8.67
Rate for Payer: Ohana Health Plan Medicaid	$3.75
Rate for Payer: Ohana Health Plan Medicare	$3.75
Rate for Payer: UnitedHealthcare Medicaid	$5.36
Rate for Payer: UnitedHealthcare Medicare	$3.75
Rate for Payer: University Health Alliance Commercial	$6.52

levalbuterol 1.25 mg/3 mL Neb Soln [KMC]

Facility

$2.67

Service Code	HCPCS J7614
Hospital Revenue Code	636
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.74
Rate for Payer: Health Management Network Commercial	$2.27
Rate for Payer: Kaiser Permanente Commercial	$2.40
Rate for Payer: MDX Hawaii PPO	$2.59

levalbuterol 1.25 mg/3 mL Neb Soln [KMC]

Facility

$2.67

Service Code	HCPCS J7614
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$2.59
Rate for Payer: AlohaCare Medicaid	$1.33
Rate for Payer: AlohaCare Medicare	$1.12
Rate for Payer: Cash Price	$1.74
Rate for Payer: Cash Price	$1.74
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.46
Rate for Payer: Devoted Health Medicare	$1.12
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.09
Rate for Payer: Hawaii Medical Service Association Medicare	$1.12
Rate for Payer: Hawaii Western Management Group Commercial	$2.54
Rate for Payer: Health Management Network Commercial	$2.27
Rate for Payer: Humana Medicare	$1.12
Rate for Payer: Kaiser Permanente Commercial	$2.40
Rate for Payer: Kaiser Permanente Medicaid	$1.36
Rate for Payer: Kaiser Permanente Medicare	$1.12
Rate for Payer: MDX Hawaii PPO	$2.59
Rate for Payer: Ohana Health Plan Medicaid	$1.12
Rate for Payer: Ohana Health Plan Medicare	$1.12
Rate for Payer: UnitedHealthcare Medicaid	$1.60
Rate for Payer: UnitedHealthcare Medicare	$1.12
Rate for Payer: University Health Alliance Commercial	$1.95

levETIRAcetam 250 mg Tab [KMC]

Facility

$11.50

Service Code	NDC 16714035401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$11.15
Rate for Payer: AlohaCare Medicaid	$5.75
Rate for Payer: AlohaCare Medicare	$4.83
Rate for Payer: Cash Price	$7.48
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.58
Rate for Payer: Devoted Health Medicare	$4.83
Rate for Payer: Hawaii Medical Service Association Medicare	$4.83
Rate for Payer: Hawaii Western Management Group Commercial	$10.93
Rate for Payer: Health Management Network Commercial	$9.78
Rate for Payer: Humana Medicare	$4.83
Rate for Payer: Kaiser Permanente Commercial	$10.35
Rate for Payer: Kaiser Permanente Medicaid	$5.87
Rate for Payer: Kaiser Permanente Medicare	$4.83
Rate for Payer: MDX Hawaii PPO	$11.15
Rate for Payer: Ohana Health Plan Medicaid	$4.83
Rate for Payer: Ohana Health Plan Medicare	$4.83
Rate for Payer: UnitedHealthcare Medicaid	$6.90
Rate for Payer: UnitedHealthcare Medicare	$4.83
Rate for Payer: University Health Alliance Commercial	$8.38

levETIRAcetam 250 mg Tab [KMC]

Facility

$11.50

Service Code	NDC 16714035401
Hospital Revenue Code	250
Min. Negotiated Rate	$9.78
Max. Negotiated Rate	$11.15
Rate for Payer: Cash Price	$7.48
Rate for Payer: Health Management Network Commercial	$9.78
Rate for Payer: Kaiser Permanente Commercial	$10.35
Rate for Payer: MDX Hawaii PPO	$11.15

levETIRAcetam 500 mg/5 mL IV Sol [KMC]

Facility

$5.95

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$5.77
Rate for Payer: Cash Price	$3.87
Rate for Payer: Health Management Network Commercial	$5.06
Rate for Payer: Kaiser Permanente Commercial	$5.36
Rate for Payer: MDX Hawaii PPO	$5.77

levETIRAcetam 500 mg/5 mL IV Sol [KMC]

Facility

$5.95

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$5.77
Rate for Payer: AlohaCare Medicaid	$2.98
Rate for Payer: AlohaCare Medicare	$2.50
Rate for Payer: Cash Price	$3.87
Rate for Payer: Cash Price	$3.87
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.47
Rate for Payer: Devoted Health Medicare	$2.50
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Medicare	$2.50
Rate for Payer: Hawaii Western Management Group Commercial	$5.65
Rate for Payer: Health Management Network Commercial	$5.06
Rate for Payer: Humana Medicare	$2.50
Rate for Payer: Kaiser Permanente Commercial	$5.36
Rate for Payer: Kaiser Permanente Medicaid	$3.03
Rate for Payer: Kaiser Permanente Medicare	$2.50
Rate for Payer: MDX Hawaii PPO	$5.77
Rate for Payer: Ohana Health Plan Medicaid	$2.50
Rate for Payer: Ohana Health Plan Medicare	$2.50
Rate for Payer: UnitedHealthcare Medicaid	$3.57
Rate for Payer: UnitedHealthcare Medicare	$2.50
Rate for Payer: University Health Alliance Commercial	$4.34

levETIRAcetam 500 mg/5 mL ORAL Liquid [KMC]

Facility

$2.60

Service Code	NDC 69452041288
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$2.52
Rate for Payer: AlohaCare Medicaid	$1.30
Rate for Payer: AlohaCare Medicare	$1.09
Rate for Payer: Cash Price	$1.69
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.39
Rate for Payer: Devoted Health Medicare	$1.09
Rate for Payer: Hawaii Medical Service Association Medicare	$1.09
Rate for Payer: Hawaii Western Management Group Commercial	$2.47
Rate for Payer: Health Management Network Commercial	$2.21
Rate for Payer: Humana Medicare	$1.09
Rate for Payer: Kaiser Permanente Commercial	$2.34
Rate for Payer: Kaiser Permanente Medicaid	$1.33
Rate for Payer: Kaiser Permanente Medicare	$1.09
Rate for Payer: MDX Hawaii PPO	$2.52
Rate for Payer: Ohana Health Plan Medicaid	$1.09
Rate for Payer: Ohana Health Plan Medicare	$1.09
Rate for Payer: UnitedHealthcare Medicaid	$1.56
Rate for Payer: UnitedHealthcare Medicare	$1.09
Rate for Payer: University Health Alliance Commercial	$1.90

levETIRAcetam 500 mg/5 mL ORAL Liquid [KMC]

Facility

$2.60

Service Code	NDC 69452041288
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$2.52
Rate for Payer: Cash Price	$1.69
Rate for Payer: Health Management Network Commercial	$2.21
Rate for Payer: Kaiser Permanente Commercial	$2.34
Rate for Payer: MDX Hawaii PPO	$2.52

levETIRAcetam 500 mg Tab [KMC]

Facility

$14.06

Service Code	NDC 72205009592
Hospital Revenue Code	250
Min. Negotiated Rate	$5.91
Max. Negotiated Rate	$13.64
Rate for Payer: AlohaCare Medicaid	$7.03
Rate for Payer: AlohaCare Medicare	$5.91
Rate for Payer: Cash Price	$9.14
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.94
Rate for Payer: Devoted Health Medicare	$5.91
Rate for Payer: Hawaii Medical Service Association Medicare	$5.91
Rate for Payer: Hawaii Western Management Group Commercial	$13.36
Rate for Payer: Health Management Network Commercial	$11.95
Rate for Payer: Humana Medicare	$5.91
Rate for Payer: Kaiser Permanente Commercial	$12.65
Rate for Payer: Kaiser Permanente Medicaid	$7.17
Rate for Payer: Kaiser Permanente Medicare	$5.91
Rate for Payer: MDX Hawaii PPO	$13.64
Rate for Payer: Ohana Health Plan Medicaid	$5.91
Rate for Payer: Ohana Health Plan Medicare	$5.91
Rate for Payer: UnitedHealthcare Medicaid	$8.44
Rate for Payer: UnitedHealthcare Medicare	$5.91
Rate for Payer: University Health Alliance Commercial	$10.25

levETIRAcetam 500 mg Tab [KMC]

Facility

$14.06

Service Code	NDC 72205009592
Hospital Revenue Code	250
Min. Negotiated Rate	$11.95
Max. Negotiated Rate	$13.64
Rate for Payer: Cash Price	$9.14
Rate for Payer: Health Management Network Commercial	$11.95
Rate for Payer: Kaiser Permanente Commercial	$12.65
Rate for Payer: MDX Hawaii PPO	$13.64

levETIRAcetam 750 mg Tab [KMC]

Facility

$19.04

Service Code	NDC 72205009692
Hospital Revenue Code	250
Min. Negotiated Rate	$16.18
Max. Negotiated Rate	$18.47
Rate for Payer: Cash Price	$12.38
Rate for Payer: Health Management Network Commercial	$16.18
Rate for Payer: Kaiser Permanente Commercial	$17.14
Rate for Payer: MDX Hawaii PPO	$18.47

levETIRAcetam 750 mg Tab [KMC]

Facility

$19.04

Service Code	NDC 72205009692
Hospital Revenue Code	250
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$18.47
Rate for Payer: AlohaCare Medicaid	$9.52
Rate for Payer: AlohaCare Medicare	$8.00
Rate for Payer: Cash Price	$12.38
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$17.52
Rate for Payer: Devoted Health Medicare	$8.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8.00
Rate for Payer: Hawaii Western Management Group Commercial	$18.09
Rate for Payer: Health Management Network Commercial	$16.18
Rate for Payer: Humana Medicare	$8.00
Rate for Payer: Kaiser Permanente Commercial	$17.14
Rate for Payer: Kaiser Permanente Medicaid	$9.71
Rate for Payer: Kaiser Permanente Medicare	$8.00
Rate for Payer: MDX Hawaii PPO	$18.47
Rate for Payer: Ohana Health Plan Medicaid	$8.00
Rate for Payer: Ohana Health Plan Medicare	$8.00
Rate for Payer: UnitedHealthcare Medicaid	$11.42
Rate for Payer: UnitedHealthcare Medicare	$8.00
Rate for Payer: University Health Alliance Commercial	$13.88

Levetiracetam DLS

Facility

$686.00

Service Code	HCPCS 80299
Hospital Charge Code	422802995
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$665.42
Rate for Payer: AlohaCare Medicaid	$343.00
Rate for Payer: AlohaCare Medicare	$288.12
Rate for Payer: Cash Price	$445.90
Rate for Payer: Cash Price	$445.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$631.12
Rate for Payer: Devoted Health Medicare	$288.12
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.92
Rate for Payer: Hawaii Medical Service Association Commercial	$23.30
Rate for Payer: Hawaii Medical Service Association Medicare	$288.12
Rate for Payer: Hawaii Western Management Group Commercial	$18.64
Rate for Payer: Health Management Network Commercial	$583.10
Rate for Payer: Humana Medicare	$288.12
Rate for Payer: Kaiser Permanente Commercial	$617.40
Rate for Payer: Kaiser Permanente Medicaid	$349.86
Rate for Payer: Kaiser Permanente Medicare	$288.12
Rate for Payer: MDX Hawaii PPO	$665.42
Rate for Payer: Ohana Health Plan Medicaid	$288.12
Rate for Payer: Ohana Health Plan Medicare	$288.12
Rate for Payer: UnitedHealthcare Medicaid	$18.92
Rate for Payer: UnitedHealthcare Medicare	$288.12
Rate for Payer: University Health Alliance Commercial	$35.39

Levetiracetam DLS

Facility

$686.00

Service Code	HCPCS 80299
Hospital Charge Code	422802995
Hospital Revenue Code	301
Min. Negotiated Rate	$583.10
Max. Negotiated Rate	$665.42
Rate for Payer: Cash Price	$445.90
Rate for Payer: Health Management Network Commercial	$583.10
Rate for Payer: Kaiser Permanente Commercial	$617.40
Rate for Payer: MDX Hawaii PPO	$665.42

levocetirizine 5 mg Tab [KMC]

Facility

$12.31

Service Code	NDC 50228013630
Hospital Revenue Code	250
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$11.94
Rate for Payer: AlohaCare Medicaid	$6.16
Rate for Payer: AlohaCare Medicare	$5.17
Rate for Payer: Cash Price	$8.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$11.33
Rate for Payer: Devoted Health Medicare	$5.17
Rate for Payer: Hawaii Medical Service Association Medicare	$5.17
Rate for Payer: Hawaii Western Management Group Commercial	$11.69
Rate for Payer: Health Management Network Commercial	$10.46
Rate for Payer: Humana Medicare	$5.17
Rate for Payer: Kaiser Permanente Commercial	$11.08
Rate for Payer: Kaiser Permanente Medicaid	$6.28
Rate for Payer: Kaiser Permanente Medicare	$5.17
Rate for Payer: MDX Hawaii PPO	$11.94
Rate for Payer: Ohana Health Plan Medicaid	$5.17
Rate for Payer: Ohana Health Plan Medicare	$5.17
Rate for Payer: UnitedHealthcare Medicaid	$7.39
Rate for Payer: UnitedHealthcare Medicare	$5.17
Rate for Payer: University Health Alliance Commercial	$8.97

Know your out-of-pocket cost for care.

All Charges