Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$41,336.29

Service Code	MSDRG 434
Min. Negotiated Rate	$41,336.29
Max. Negotiated Rate	$41,336.29
Rate for Payer: Hawaii Medical Service Association Commercial	$41,336.29

citalopram 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 76282062890
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

citalopram 10 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 76282062890
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

citalopram 40 mg Tab [KMC]

Facility

$11.12

Service Code	NDC 13668001101
Hospital Revenue Code	250
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$10.79
Rate for Payer: Cash Price	$7.23
Rate for Payer: Health Management Network Commercial	$9.45
Rate for Payer: Kaiser Permanente Commercial	$10.01
Rate for Payer: MDX Hawaii PPO	$10.79

citalopram 40 mg Tab [KMC]

Facility

$11.12

Service Code	NDC 13668001101
Hospital Revenue Code	250
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$10.79
Rate for Payer: AlohaCare Medicaid	$5.56
Rate for Payer: AlohaCare Medicare	$4.67
Rate for Payer: Cash Price	$7.23
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10.23
Rate for Payer: Devoted Health Medicare	$4.67
Rate for Payer: Hawaii Medical Service Association Medicare	$4.67
Rate for Payer: Hawaii Western Management Group Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$9.45
Rate for Payer: Humana Medicare	$4.67
Rate for Payer: Kaiser Permanente Commercial	$10.01
Rate for Payer: Kaiser Permanente Medicaid	$5.67
Rate for Payer: Kaiser Permanente Medicare	$4.67
Rate for Payer: MDX Hawaii PPO	$10.79
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.67
Rate for Payer: UnitedHealthcare Medicaid	$6.67
Rate for Payer: UnitedHealthcare Medicare	$4.67
Rate for Payer: University Health Alliance Commercial	$8.11

CK MB DLS

Facility

$241.00

Service Code	HCPCS 82553
Hospital Charge Code	422825535
Hospital Revenue Code	301
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$233.77
Rate for Payer: Cash Price	$156.65
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: MDX Hawaii PPO	$233.77

CK MB DLS

Facility

$241.00

Service Code	HCPCS 82553
Hospital Charge Code	422825535
Hospital Revenue Code	301
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$233.77
Rate for Payer: AlohaCare Medicaid	$120.50
Rate for Payer: AlohaCare Medicare	$101.22
Rate for Payer: Cash Price	$156.65
Rate for Payer: Cash Price	$156.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$221.72
Rate for Payer: Devoted Health Medicare	$101.22
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.44
Rate for Payer: Hawaii Medical Service Association Medicare	$101.22
Rate for Payer: Hawaii Western Management Group Commercial	$11.55
Rate for Payer: Health Management Network Commercial	$204.85
Rate for Payer: Humana Medicare	$101.22
Rate for Payer: Kaiser Permanente Commercial	$216.90
Rate for Payer: Kaiser Permanente Medicaid	$122.91
Rate for Payer: Kaiser Permanente Medicare	$101.22
Rate for Payer: MDX Hawaii PPO	$233.77
Rate for Payer: Ohana Health Plan Medicaid	$101.22
Rate for Payer: Ohana Health Plan Medicare	$101.22
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$101.22
Rate for Payer: University Health Alliance Commercial	$29.84

CK, Total DLS

Facility

$103.00

Service Code	HCPCS 82550
Hospital Charge Code	422825505
Hospital Revenue Code	301
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$99.91
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$43.26
Rate for Payer: Cash Price	$66.95
Rate for Payer: Cash Price	$66.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$94.76
Rate for Payer: Devoted Health Medicare	$43.26
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$9.01
Rate for Payer: Hawaii Medical Service Association Commercial	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$43.26
Rate for Payer: Hawaii Western Management Group Commercial	$6.51
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$43.26
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$43.26
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$43.26
Rate for Payer: Ohana Health Plan Medicare	$43.26
Rate for Payer: UnitedHealthcare Medicaid	$9.01
Rate for Payer: UnitedHealthcare Medicare	$43.26
Rate for Payer: University Health Alliance Commercial	$16.84

CK, Total DLS

Facility

$103.00

Service Code	HCPCS 82550
Hospital Charge Code	422825505
Hospital Revenue Code	301
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$66.95
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: MDX Hawaii PPO	$99.91

clarithromycin 500 mg ER Tab [KMC]

Facility

$20.03

Service Code	NDC 62037077760
Hospital Revenue Code	250
Min. Negotiated Rate	$17.03
Max. Negotiated Rate	$19.43
Rate for Payer: Cash Price	$13.02
Rate for Payer: Health Management Network Commercial	$17.03
Rate for Payer: Kaiser Permanente Commercial	$18.03
Rate for Payer: MDX Hawaii PPO	$19.43

clarithromycin 500 mg ER Tab [KMC]

Facility

$20.03

Service Code	NDC 62037077760
Hospital Revenue Code	250
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$19.43
Rate for Payer: AlohaCare Medicaid	$10.02
Rate for Payer: AlohaCare Medicare	$8.41
Rate for Payer: Cash Price	$13.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$18.43
Rate for Payer: Devoted Health Medicare	$8.41
Rate for Payer: Hawaii Medical Service Association Medicare	$8.41
Rate for Payer: Hawaii Western Management Group Commercial	$19.03
Rate for Payer: Health Management Network Commercial	$17.03
Rate for Payer: Humana Medicare	$8.41
Rate for Payer: Kaiser Permanente Commercial	$18.03
Rate for Payer: Kaiser Permanente Medicaid	$10.22
Rate for Payer: Kaiser Permanente Medicare	$8.41
Rate for Payer: MDX Hawaii PPO	$19.43
Rate for Payer: Ohana Health Plan Medicaid	$8.41
Rate for Payer: Ohana Health Plan Medicare	$8.41
Rate for Payer: UnitedHealthcare Medicaid	$12.02
Rate for Payer: UnitedHealthcare Medicare	$8.41
Rate for Payer: University Health Alliance Commercial	$14.60

clarithromycin 500 mg Tab [KMC]

Facility

$24.06

Service Code	NDC 65862022660
Hospital Revenue Code	250
Min. Negotiated Rate	$20.45
Max. Negotiated Rate	$23.34
Rate for Payer: Cash Price	$15.64
Rate for Payer: Health Management Network Commercial	$20.45
Rate for Payer: Kaiser Permanente Commercial	$21.65
Rate for Payer: MDX Hawaii PPO	$23.34

clarithromycin 500 mg Tab [KMC]

Facility

$24.06

Service Code	NDC 65862022660
Hospital Revenue Code	250
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$23.34
Rate for Payer: AlohaCare Medicaid	$12.03
Rate for Payer: AlohaCare Medicare	$10.11
Rate for Payer: Cash Price	$15.64
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.14
Rate for Payer: Devoted Health Medicare	$10.11
Rate for Payer: Hawaii Medical Service Association Medicare	$10.11
Rate for Payer: Hawaii Western Management Group Commercial	$22.86
Rate for Payer: Health Management Network Commercial	$20.45
Rate for Payer: Humana Medicare	$10.11
Rate for Payer: Kaiser Permanente Commercial	$21.65
Rate for Payer: Kaiser Permanente Medicaid	$12.27
Rate for Payer: Kaiser Permanente Medicare	$10.11
Rate for Payer: MDX Hawaii PPO	$23.34
Rate for Payer: Ohana Health Plan Medicaid	$10.11
Rate for Payer: Ohana Health Plan Medicare	$10.11
Rate for Payer: UnitedHealthcare Medicaid	$14.44
Rate for Payer: UnitedHealthcare Medicare	$10.11
Rate for Payer: University Health Alliance Commercial	$17.54

CLAVICAL SPLINT XSM

Facility

$3.00

Hospital Charge Code	8448
Hospital Revenue Code	274
Min. Negotiated Rate	$1.68
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Hawaii Western Management Group Commercial	$2.10
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
Rate for Payer: University Health Alliance Commercial	$1.68

CLAVICAL SPLINT XSM

Facility

$3.00

Hospital Charge Code	8448
Hospital Revenue Code	274
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	$2.10
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$1.68

CLAVICAL STRAP LG

Facility

$3.00

Hospital Charge Code	8062
Hospital Revenue Code	270
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

CLAVICAL STRAP LG

Facility

$3.00

Hospital Charge Code	8062
Hospital Revenue Code	270
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

CLAVICAL STRAP MED

Facility

$6.00

Hospital Charge Code	8063
Hospital Revenue Code	270
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

CLAVICAL STRAP MED

Facility

$6.00

Hospital Charge Code	8063
Hospital Revenue Code	270
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

CLAVICAL STRAP SM

Facility

$51.00

Hospital Charge Code	8064
Hospital Revenue Code	270
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$21.42
Rate for Payer: Cash Price	$33.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.92
Rate for Payer: Devoted Health Medicare	$21.42
Rate for Payer: Hawaii Medical Service Association Medicare	$21.42
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$21.42
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$21.42
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$21.42
Rate for Payer: Ohana Health Plan Medicare	$21.42
Rate for Payer: UnitedHealthcare Medicare	$21.42
Rate for Payer: University Health Alliance Commercial	$37.17

CLAVICAL STRAP SM

Facility

$51.00

Hospital Charge Code	8064
Hospital Revenue Code	270
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$33.15
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

CLAVICAL STRAP XL

Facility

$6.00

Hospital Charge Code	8065
Hospital Revenue Code	270
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

CLAVICAL STRAP XL

Facility

$6.00

Hospital Charge Code	8065
Hospital Revenue Code	270
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

CLEAR OUTER EAR CANAL CHARGE

Facility

$275.00

Service Code	HCPCS 69200
Hospital Charge Code	440692000
Hospital Revenue Code	450
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$137.50
Rate for Payer: AlohaCare Medicare	$115.50
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$253.00
Rate for Payer: Devoted Health Medicare	$115.50
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	$115.50
Rate for Payer: Hawaii Western Management Group Commercial	$261.25
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Humana Medicare	$115.50
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$115.50
Rate for Payer: MDX Hawaii PPO	$266.75
Rate for Payer: Ohana Health Plan Medicaid	$115.50
Rate for Payer: Ohana Health Plan Medicare	$115.50
Rate for Payer: UnitedHealthcare Medicare	$115.50
Rate for Payer: University Health Alliance Commercial	$200.45

CLEAR OUTER EAR CANAL CHARGE

Facility

$275.00

Service Code	HCPCS 69200
Hospital Charge Code	440692000
Hospital Revenue Code	450
Min. Negotiated Rate	$233.75
Max. Negotiated Rate	$266.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Health Management Network Commercial	$233.75
Rate for Payer: Kaiser Permanente Commercial	$247.50
Rate for Payer: MDX Hawaii PPO	$266.75

Know your out-of-pocket cost for care.

All Charges