Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

labetalol 100 mg tablet [HHSC]

Facility

$3.03

Service Code	NDC 60687043901
Hospital Charge Code	2500442
Hospital Revenue Code	250
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.94
Rate for Payer: AlohaCare Medicaid	$1.51
Rate for Payer: AlohaCare Medicare	$1.51
Rate for Payer: Cash Price	$1.97
Rate for Payer: Devoted Health Medicare	$1.67
Rate for Payer: Hawaii Medical Service Association Medicare	$1.51
Rate for Payer: Hawaii Western Management Group Commercial	$2.88
Rate for Payer: Health Management Network Commercial	$2.58
Rate for Payer: Humana Medicare	$1.51
Rate for Payer: Kaiser Permanente Commercial	$2.73
Rate for Payer: Kaiser Permanente Medicaid	$1.55
Rate for Payer: Kaiser Permanente Medicare	$1.51
Rate for Payer: MDX Hawaii PPO	$2.94
Rate for Payer: Ohana Health Plan Medicaid	$1.51
Rate for Payer: Ohana Health Plan Medicare	$1.51
Rate for Payer: UnitedHealthcare Medicaid	$1.82
Rate for Payer: UnitedHealthcare Medicare	$1.51
Rate for Payer: University Health Alliance Commercial	$2.21

labetalol 100 mg tablet [HHSC]

Facility

$3.06

Service Code	NDC 60687011401
Hospital Charge Code	2500442
Hospital Revenue Code	250
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.97
Rate for Payer: AlohaCare Medicaid	$1.53
Rate for Payer: AlohaCare Medicare	$1.53
Rate for Payer: Cash Price	$1.99
Rate for Payer: Devoted Health Medicare	$1.68
Rate for Payer: Hawaii Medical Service Association Medicare	$1.53
Rate for Payer: Hawaii Western Management Group Commercial	$2.91
Rate for Payer: Health Management Network Commercial	$2.60
Rate for Payer: Humana Medicare	$1.53
Rate for Payer: Kaiser Permanente Commercial	$2.75
Rate for Payer: Kaiser Permanente Medicaid	$1.56
Rate for Payer: Kaiser Permanente Medicare	$1.53
Rate for Payer: MDX Hawaii PPO	$2.97
Rate for Payer: Ohana Health Plan Medicaid	$1.53
Rate for Payer: Ohana Health Plan Medicare	$1.53
Rate for Payer: UnitedHealthcare Medicaid	$1.84
Rate for Payer: UnitedHealthcare Medicare	$1.53
Rate for Payer: University Health Alliance Commercial	$2.23

labetalol 100 mg tablet [HHSC]

Facility

$12.68

Service Code	NDC 00904592861
Hospital Charge Code	2500442
Hospital Revenue Code	250
Min. Negotiated Rate	$10.78
Max. Negotiated Rate	$12.30
Rate for Payer: Cash Price	$8.24
Rate for Payer: Health Management Network Commercial	$10.78
Rate for Payer: Kaiser Permanente Commercial	$11.41
Rate for Payer: MDX Hawaii PPO	$12.30

labetalol 100 mg tablet [HHSC]

Facility

$12.68

Service Code	NDC 00904592861
Hospital Charge Code	2500442
Hospital Revenue Code	250
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$12.30
Rate for Payer: AlohaCare Medicaid	$6.34
Rate for Payer: AlohaCare Medicare	$6.34
Rate for Payer: Cash Price	$8.24
Rate for Payer: Devoted Health Medicare	$6.97
Rate for Payer: Hawaii Medical Service Association Medicare	$6.34
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$10.78
Rate for Payer: Humana Medicare	$6.34
Rate for Payer: Kaiser Permanente Commercial	$11.41
Rate for Payer: Kaiser Permanente Medicaid	$6.47
Rate for Payer: Kaiser Permanente Medicare	$6.34
Rate for Payer: MDX Hawaii PPO	$12.30
Rate for Payer: Ohana Health Plan Medicaid	$6.34
Rate for Payer: Ohana Health Plan Medicare	$6.34
Rate for Payer: UnitedHealthcare Medicaid	$7.61
Rate for Payer: UnitedHealthcare Medicare	$6.34
Rate for Payer: University Health Alliance Commercial	$9.24

labetalol 100 mg tablet [HHSC]

Facility

$3.06

Service Code	NDC 60687011401
Hospital Charge Code	2500442
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$2.97
Rate for Payer: Cash Price	$1.99
Rate for Payer: Health Management Network Commercial	$2.60
Rate for Payer: Kaiser Permanente Commercial	$2.75
Rate for Payer: MDX Hawaii PPO	$2.97

labetalol 100 mg tablet [HHSC]

Facility

$3.03

Service Code	NDC 60687043901
Hospital Charge Code	2500442
Hospital Revenue Code	250
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$2.94
Rate for Payer: Cash Price	$1.97
Rate for Payer: Health Management Network Commercial	$2.58
Rate for Payer: Kaiser Permanente Commercial	$2.73
Rate for Payer: MDX Hawaii PPO	$2.94

Labor Care Level 1 Per Hr Charge

Facility

$160.00

Hospital Charge Code	8140411
Hospital Revenue Code	721
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$155.20
Rate for Payer: AlohaCare Medicaid	$80.00
Rate for Payer: AlohaCare Medicare	$80.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Devoted Health Medicare	$88.00
Rate for Payer: Hawaii Medical Service Association Medicare	$80.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Humana Medicare	$80.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: Kaiser Permanente Medicare	$80.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: Ohana Health Plan Medicaid	$80.00
Rate for Payer: Ohana Health Plan Medicare	$80.00
Rate for Payer: UnitedHealthcare Medicare	$80.00
Rate for Payer: University Health Alliance Commercial	$89.60

Labor Care Level 1 Per Hr Charge

Facility

$160.00

Hospital Charge Code	8140411
Hospital Revenue Code	721
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$144.00
Rate for Payer: MDX Hawaii PPO	$155.20

Labor Care Level 2 Per Hr Charge

Facility

$230.00

Hospital Charge Code	8140412
Hospital Revenue Code	721
Min. Negotiated Rate	$115.00
Max. Negotiated Rate	$223.10
Rate for Payer: AlohaCare Medicaid	$115.00
Rate for Payer: AlohaCare Medicare	$115.00
Rate for Payer: Cash Price	$149.50
Rate for Payer: Devoted Health Medicare	$126.50
Rate for Payer: Hawaii Medical Service Association Medicare	$115.00
Rate for Payer: Hawaii Western Management Group Commercial	$218.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Humana Medicare	$115.00
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: Kaiser Permanente Medicare	$115.00
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: Ohana Health Plan Medicaid	$115.00
Rate for Payer: Ohana Health Plan Medicare	$115.00
Rate for Payer: UnitedHealthcare Medicare	$115.00
Rate for Payer: University Health Alliance Commercial	$128.80

Labor Care Level 2 Per Hr Charge

Facility

$230.00

Hospital Charge Code	8140412
Hospital Revenue Code	721
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$149.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: MDX Hawaii PPO	$223.10

Labor Induction Aug Addl Hr Charge

Facility

$356.00

Hospital Charge Code	8140419
Hospital Revenue Code	721
Min. Negotiated Rate	$302.60
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$231.40
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: MDX Hawaii PPO	$345.32

Labor Induction Aug Addl Hr Charge

Facility

$356.00

Hospital Charge Code	8140419
Hospital Revenue Code	721
Min. Negotiated Rate	$178.00
Max. Negotiated Rate	$345.32
Rate for Payer: AlohaCare Medicaid	$178.00
Rate for Payer: AlohaCare Medicare	$178.00
Rate for Payer: Cash Price	$231.40
Rate for Payer: Devoted Health Medicare	$195.80
Rate for Payer: Hawaii Medical Service Association Medicare	$178.00
Rate for Payer: Hawaii Western Management Group Commercial	$338.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Humana Medicare	$178.00
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: Kaiser Permanente Medicaid	$181.56
Rate for Payer: Kaiser Permanente Medicare	$178.00
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: Ohana Health Plan Medicaid	$178.00
Rate for Payer: Ohana Health Plan Medicare	$178.00
Rate for Payer: UnitedHealthcare Medicare	$178.00
Rate for Payer: University Health Alliance Commercial	$199.36

Labor Induction Aug Initial Hr Charge

Facility

$805.00

Hospital Charge Code	8140420
Hospital Revenue Code	721
Min. Negotiated Rate	$684.25
Max. Negotiated Rate	$780.85
Rate for Payer: Cash Price	$523.25
Rate for Payer: Health Management Network Commercial	$684.25
Rate for Payer: Kaiser Permanente Commercial	$724.50
Rate for Payer: MDX Hawaii PPO	$780.85

Labor Induction Aug Initial Hr Charge

Facility

$805.00

Hospital Charge Code	8140420
Hospital Revenue Code	721
Min. Negotiated Rate	$402.50
Max. Negotiated Rate	$780.85
Rate for Payer: AlohaCare Medicaid	$402.50
Rate for Payer: AlohaCare Medicare	$402.50
Rate for Payer: Cash Price	$523.25
Rate for Payer: Devoted Health Medicare	$442.75
Rate for Payer: Hawaii Medical Service Association Medicare	$402.50
Rate for Payer: Hawaii Western Management Group Commercial	$764.75
Rate for Payer: Health Management Network Commercial	$684.25
Rate for Payer: Humana Medicare	$402.50
Rate for Payer: Kaiser Permanente Commercial	$724.50
Rate for Payer: Kaiser Permanente Medicaid	$410.55
Rate for Payer: Kaiser Permanente Medicare	$402.50
Rate for Payer: MDX Hawaii PPO	$780.85
Rate for Payer: Ohana Health Plan Medicaid	$402.50
Rate for Payer: Ohana Health Plan Medicare	$402.50
Rate for Payer: UnitedHealthcare Medicare	$402.50
Rate for Payer: University Health Alliance Commercial	$450.80

Lacosamide- Bill only

Facility

$299.00

Service Code	HCPCS 80235
Hospital Charge Code	12514766
Hospital Revenue Code	301
Min. Negotiated Rate	$254.15
Max. Negotiated Rate	$290.03
Rate for Payer: Cash Price	$194.35
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: MDX Hawaii PPO	$290.03

Lacosamide- Bill only

Facility

$299.00

Service Code	HCPCS 80235
Hospital Charge Code	12514766
Hospital Revenue Code	301
Min. Negotiated Rate	$16.27
Max. Negotiated Rate	$290.03
Rate for Payer: AlohaCare Medicaid	$149.50
Rate for Payer: AlohaCare Medicare	$149.50
Rate for Payer: Cash Price	$194.35
Rate for Payer: Cash Price	$194.35
Rate for Payer: Devoted Health Medicare	$164.45
Rate for Payer: Hawaii Medical Service Association ABD	$26.21
Rate for Payer: Hawaii Medical Service Association Commercial	$33.89
Rate for Payer: Hawaii Medical Service Association Medicare	$149.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.21
Rate for Payer: Hawaii Western Management Group Commercial	$27.11
Rate for Payer: Health Management Network Commercial	$254.15
Rate for Payer: Humana Medicare	$149.50
Rate for Payer: Kaiser Permanente Commercial	$269.10
Rate for Payer: Kaiser Permanente Medicaid	$152.49
Rate for Payer: Kaiser Permanente Medicare	$149.50
Rate for Payer: MDX Hawaii PPO	$290.03
Rate for Payer: Ohana Health Plan Medicaid	$149.50
Rate for Payer: Ohana Health Plan Medicare	$149.50
Rate for Payer: UnitedHealthcare Medicaid	$16.27
Rate for Payer: UnitedHealthcare Medicare	$149.50
Rate for Payer: University Health Alliance Commercial	$167.44

Lacosamide Level FSI

Facility

$314.00

Service Code	HCPCS 80235
Hospital Charge Code	12346780
Hospital Revenue Code	301
Min. Negotiated Rate	$266.90
Max. Negotiated Rate	$304.58
Rate for Payer: Cash Price	$204.10
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Kaiser Permanente Commercial	$282.60
Rate for Payer: MDX Hawaii PPO	$304.58

Lacosamide Level FSI

Facility

$314.00

Service Code	HCPCS 80235
Hospital Charge Code	12346780
Hospital Revenue Code	301
Min. Negotiated Rate	$16.27
Max. Negotiated Rate	$304.58
Rate for Payer: AlohaCare Medicaid	$157.00
Rate for Payer: AlohaCare Medicare	$157.00
Rate for Payer: Cash Price	$204.10
Rate for Payer: Cash Price	$204.10
Rate for Payer: Devoted Health Medicare	$172.70
Rate for Payer: Hawaii Medical Service Association ABD	$26.21
Rate for Payer: Hawaii Medical Service Association Commercial	$33.89
Rate for Payer: Hawaii Medical Service Association Medicare	$157.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.21
Rate for Payer: Hawaii Western Management Group Commercial	$27.11
Rate for Payer: Health Management Network Commercial	$266.90
Rate for Payer: Humana Medicare	$157.00
Rate for Payer: Kaiser Permanente Commercial	$282.60
Rate for Payer: Kaiser Permanente Medicaid	$160.14
Rate for Payer: Kaiser Permanente Medicare	$157.00
Rate for Payer: MDX Hawaii PPO	$304.58
Rate for Payer: Ohana Health Plan Medicaid	$157.00
Rate for Payer: Ohana Health Plan Medicare	$157.00
Rate for Payer: UnitedHealthcare Medicaid	$16.27
Rate for Payer: UnitedHealthcare Medicare	$157.00
Rate for Payer: University Health Alliance Commercial	$175.84

Lactate Arterial POCT

Facility

$161.00

Service Code	HCPCS 83605
Hospital Charge Code	9364575
Hospital Revenue Code	301
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$104.65
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: MDX Hawaii PPO	$156.17

Lactate Arterial POCT

Facility

$161.00

Service Code	HCPCS 83605
Hospital Charge Code	9364575
Hospital Revenue Code	301
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$156.17
Rate for Payer: AlohaCare Medicaid	$80.50
Rate for Payer: AlohaCare Medicare	$80.50
Rate for Payer: Cash Price	$104.65
Rate for Payer: Cash Price	$104.65
Rate for Payer: Devoted Health Medicare	$88.55
Rate for Payer: Hawaii Medical Service Association ABD	$14.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$80.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Humana Medicare	$80.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$82.11
Rate for Payer: Kaiser Permanente Medicare	$80.50
Rate for Payer: MDX Hawaii PPO	$156.17
Rate for Payer: Ohana Health Plan Medicaid	$80.50
Rate for Payer: Ohana Health Plan Medicare	$80.50
Rate for Payer: UnitedHealthcare Medicaid	$14.76
Rate for Payer: UnitedHealthcare Medicare	$80.50
Rate for Payer: University Health Alliance Commercial	$27.60

Lactated Ringers 1000 ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7120
Hospital Charge Code	2500445
Hospital Revenue Code	250
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$8.46
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: MDX Hawaii PPO	$12.62

Lactated Ringers 1000 ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7120
Hospital Charge Code	2500445
Hospital Revenue Code	636
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$12.62
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cash Price	$8.46
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association ABD	$2.46
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.46
Rate for Payer: Hawaii Western Management Group Commercial	$12.36
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: Kaiser Permanente Medicaid	$6.64
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.62
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicaid	$7.81
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

Lactate Venous POCT

Facility

$161.00

Service Code	HCPCS 83605
Hospital Charge Code	9364576
Hospital Revenue Code	301
Min. Negotiated Rate	$136.85
Max. Negotiated Rate	$156.17
Rate for Payer: Cash Price	$104.65
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: MDX Hawaii PPO	$156.17

Lactate Venous POCT

Facility

$161.00

Service Code	HCPCS 83605
Hospital Charge Code	9364576
Hospital Revenue Code	301
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$156.17
Rate for Payer: AlohaCare Medicaid	$80.50
Rate for Payer: AlohaCare Medicare	$80.50
Rate for Payer: Cash Price	$104.65
Rate for Payer: Cash Price	$104.65
Rate for Payer: Devoted Health Medicare	$88.55
Rate for Payer: Hawaii Medical Service Association ABD	$14.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$80.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Humana Medicare	$80.50
Rate for Payer: Kaiser Permanente Commercial	$144.90
Rate for Payer: Kaiser Permanente Medicaid	$82.11
Rate for Payer: Kaiser Permanente Medicare	$80.50
Rate for Payer: MDX Hawaii PPO	$156.17
Rate for Payer: Ohana Health Plan Medicaid	$80.50
Rate for Payer: Ohana Health Plan Medicare	$80.50
Rate for Payer: UnitedHealthcare Medicaid	$14.76
Rate for Payer: UnitedHealthcare Medicare	$80.50
Rate for Payer: University Health Alliance Commercial	$27.60

Lactic Acid FSI

Facility

$126.00

Service Code	HCPCS 83605
Hospital Charge Code	8228888
Hospital Revenue Code	301
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association ABD	$14.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.50
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$14.76
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$27.60

Know your out-of-pocket cost for care.

All Charges