Kau Hospital

All Charges

Charge

Type

Setting

Price

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

$153.00

Service Code	NDC 00168025846
Hospital Revenue Code	637
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$47.43
Rate for Payer: Cash Price	$91.80
Rate for Payer: Devoted Health Medicare	$52.02
Rate for Payer: Hawaii Medical Service Association Medicare	$47.43
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$47.43
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$47.43
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$47.43
Rate for Payer: Ohana Health Plan Medicare	$47.43
Rate for Payer: UnitedHealthcare Medicare	$47.43
Rate for Payer: University Health Alliance Commercial	$111.52

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

$153.00

Service Code	NDC 00168025846
Hospital Revenue Code	250
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$91.80
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

$197.00

Service Code	NDC 68462029817
Hospital Revenue Code	637
Min. Negotiated Rate	$61.07
Max. Negotiated Rate	$191.09
Rate for Payer: AlohaCare Medicaid	$98.50
Rate for Payer: AlohaCare Medicare	$61.07
Rate for Payer: Cash Price	$118.20
Rate for Payer: Devoted Health Medicare	$66.98
Rate for Payer: Hawaii Medical Service Association Medicare	$61.07
Rate for Payer: Hawaii Western Management Group Commercial	$187.15
Rate for Payer: Health Management Network Commercial	$167.45
Rate for Payer: Humana Medicare	$61.07
Rate for Payer: Kaiser Permanente Commercial	$177.30
Rate for Payer: Kaiser Permanente Medicaid	$100.47
Rate for Payer: Kaiser Permanente Medicare	$61.07
Rate for Payer: MDX Hawaii PPO	$191.09
Rate for Payer: Ohana Health Plan Medicaid	$61.07
Rate for Payer: Ohana Health Plan Medicare	$61.07
Rate for Payer: UnitedHealthcare Medicare	$61.07
Rate for Payer: University Health Alliance Commercial	$143.59

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

$293.00

Service Code	NDC 00472037945
Hospital Revenue Code	637
Min. Negotiated Rate	$90.83
Max. Negotiated Rate	$284.21
Rate for Payer: AlohaCare Medicaid	$146.50
Rate for Payer: AlohaCare Medicare	$90.83
Rate for Payer: Cash Price	$175.80
Rate for Payer: Devoted Health Medicare	$99.62
Rate for Payer: Hawaii Medical Service Association Medicare	$90.83
Rate for Payer: Hawaii Western Management Group Commercial	$278.35
Rate for Payer: Health Management Network Commercial	$249.05
Rate for Payer: Humana Medicare	$90.83
Rate for Payer: Kaiser Permanente Commercial	$263.70
Rate for Payer: Kaiser Permanente Medicaid	$149.43
Rate for Payer: Kaiser Permanente Medicare	$90.83
Rate for Payer: MDX Hawaii PPO	$284.21
Rate for Payer: Ohana Health Plan Medicaid	$90.83
Rate for Payer: Ohana Health Plan Medicare	$90.83
Rate for Payer: UnitedHealthcare Medicare	$90.83
Rate for Payer: University Health Alliance Commercial	$213.57

CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]

Facility

$136.00

Service Code	NDC 00472037915
Hospital Revenue Code	250
Min. Negotiated Rate	$115.60
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$81.60
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92

CLOZAPINE 100 MG TABLET [9647]

Facility

$13.00

Service Code	NDC 60687041511
Hospital Revenue Code	637
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$4.03
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$4.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.03
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$4.03
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$4.03
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$4.03
Rate for Payer: Ohana Health Plan Medicare	$4.03
Rate for Payer: UnitedHealthcare Medicare	$4.03
Rate for Payer: University Health Alliance Commercial	$9.48

CLOZAPINE 100 MG TABLET [9647]

Facility

$13.00

Service Code	NDC 60687041501
Hospital Revenue Code	637
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$4.03
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$4.42
Rate for Payer: Hawaii Medical Service Association Medicare	$4.03
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$4.03
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$4.03
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$4.03
Rate for Payer: Ohana Health Plan Medicare	$4.03
Rate for Payer: UnitedHealthcare Medicare	$4.03
Rate for Payer: University Health Alliance Commercial	$9.48

CLOZAPINE 100 MG TABLET [9647]

Facility

$13.00

Service Code	NDC 60687041501
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

CLOZAPINE 100 MG TABLET [9647]

Facility

$13.00

Service Code	NDC 60687041511
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

CLOZAPINE 25 MG TABLET [9648]

Facility

$5.00

Service Code	NDC 60687040401
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$1.55
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$1.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1.55
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$1.55
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$1.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$1.55
Rate for Payer: Ohana Health Plan Medicare	$1.55
Rate for Payer: UnitedHealthcare Medicare	$1.55
Rate for Payer: University Health Alliance Commercial	$3.64

CLOZAPINE 25 MG TABLET [9648]

Facility

$5.00

Service Code	NDC 60687040401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

CLOZAPINE 25 MG TABLET [9648]

Facility

$5.00

Service Code	NDC 60687040411
Hospital Revenue Code	250
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.00
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

CLOZAPINE 25 MG TABLET [9648]

Facility

$5.00

Service Code	NDC 60687040411
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$1.55
Rate for Payer: Cash Price	$3.00
Rate for Payer: Devoted Health Medicare	$1.70
Rate for Payer: Hawaii Medical Service Association Medicare	$1.55
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$1.55
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$1.55
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$1.55
Rate for Payer: Ohana Health Plan Medicare	$1.55
Rate for Payer: UnitedHealthcare Medicare	$1.55
Rate for Payer: University Health Alliance Commercial	$3.64

CLSTERHLE SHELL48MM 702-04-48D

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,005.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: AlohaCare Medicaid	$1,622.00
Rate for Payer: AlohaCare Medicare	$1,005.64
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Devoted Health Medicare	$1,102.96
Rate for Payer: Hawaii Medical Service Association Medicare	$1,005.64
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Humana Medicare	$1,005.64
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: Kaiser Permanente Medicare	$1,005.64
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: Ohana Health Plan Medicaid	$1,005.64
Rate for Payer: Ohana Health Plan Medicare	$1,005.64
Rate for Payer: UnitedHealthcare Medicare	$1,005.64
Rate for Payer: University Health Alliance Commercial	$1,816.64

CLSTERHLE SHELL48MM 702-04-48D

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,919.60
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

CLSTERHLE SHELL50MM 702-04-50D

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

CLSTERHLE SHELL50MM 702-04-50D

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$995.41
Max. Negotiated Rate	$3,114.67
Rate for Payer: AlohaCare Medicaid	$1,605.50
Rate for Payer: AlohaCare Medicare	$995.41
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Devoted Health Medicare	$1,091.74
Rate for Payer: Hawaii Medical Service Association Medicare	$995.41
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Humana Medicare	$995.41
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: Kaiser Permanente Medicare	$995.41
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: Ohana Health Plan Medicaid	$995.41
Rate for Payer: Ohana Health Plan Medicare	$995.41
Rate for Payer: UnitedHealthcare Medicare	$995.41
Rate for Payer: University Health Alliance Commercial	$1,798.16

CLSTR SHEL 50HH 00-8757-050-01

Facility

$4,684.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,623.04
Max. Negotiated Rate	$4,543.48
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: Kaiser Permanente Commercial	$4,215.60
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: University Health Alliance Commercial	$2,623.04

CLSTR SHEL 50HH 00-8757-050-01

Facility

$4,684.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,452.04
Max. Negotiated Rate	$4,543.48
Rate for Payer: AlohaCare Medicaid	$2,342.00
Rate for Payer: AlohaCare Medicare	$1,452.04
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Devoted Health Medicare	$1,592.56
Rate for Payer: Hawaii Medical Service Association Medicare	$1,452.04
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: Humana Medicare	$1,452.04
Rate for Payer: Kaiser Permanente Commercial	$4,215.60
Rate for Payer: Kaiser Permanente Medicaid	$2,388.84
Rate for Payer: Kaiser Permanente Medicare	$1,452.04
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: Ohana Health Plan Medicaid	$1,452.04
Rate for Payer: Ohana Health Plan Medicare	$1,452.04
Rate for Payer: UnitedHealthcare Medicare	$1,452.04
Rate for Payer: University Health Alliance Commercial	$2,623.04

CLSTR SHEL 54JJ 00-8757-054-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$1,364.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$1,496.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,364.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$1,364.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$1,364.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$1,364.00
Rate for Payer: Ohana Health Plan Medicare	$1,364.00
Rate for Payer: UnitedHealthcare Medicare	$1,364.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 54JJ 00-8757-054-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 56KK 00-8757-056-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$1,364.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$1,496.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,364.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$1,364.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$1,364.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$1,364.00
Rate for Payer: Ohana Health Plan Medicare	$1,364.00
Rate for Payer: UnitedHealthcare Medicare	$1,364.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 56KK 00-8757-056-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 60MM 00-8757-060-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

CLSTR SHEL 60MM 00-8757-060-01

Facility

$4,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$1,364.00
Rate for Payer: Cash Price	$2,640.00
Rate for Payer: Devoted Health Medicare	$1,496.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,364.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$1,364.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$1,364.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$1,364.00
Rate for Payer: Ohana Health Plan Medicare	$1,364.00
Rate for Payer: UnitedHealthcare Medicare	$1,364.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

Know your out-of-pocket cost for care.

All Charges