Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

citric acid-simeth-bicarb effervescent granules [HHSC]

Facility

$16.92

Service Code	HCPCS A9270
Hospital Charge Code	2501019
Hospital Revenue Code	255
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$16.41
Rate for Payer: Cash Price	$11.00
Rate for Payer: Health Management Network Commercial	$14.38
Rate for Payer: Kaiser Permanente Commercial	$15.23
Rate for Payer: MDX Hawaii PPO	$16.41

CK (CPK) FSI

Facility

$97.00

Service Code	HCPCS 82550
Hospital Charge Code	8117883
Hospital Revenue Code	301
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$48.50
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Devoted Health Medicare	$53.35
Rate for Payer: Hawaii Medical Service Association ABD	$9.01
Rate for Payer: Hawaii Medical Service Association Commercial	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.46
Rate for Payer: Hawaii Western Management Group Commercial	$6.51
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$48.50
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$48.50
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$9.01
Rate for Payer: UnitedHealthcare Medicare	$48.50
Rate for Payer: University Health Alliance Commercial	$16.84

CK (CPK) FSI

Facility

$97.00

Service Code	HCPCS 82550
Hospital Charge Code	8117883
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$63.05
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

CKMB FSI

Facility

$134.00

Service Code	HCPCS 82553
Hospital Charge Code	8228856
Hospital Revenue Code	301
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

CKMB FSI

Facility

$134.00

Service Code	HCPCS 82553
Hospital Charge Code	8228856
Hospital Revenue Code	301
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.44
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.55
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$29.84

CK, (Rfx if Elevated) FSI

Facility

$97.00

Service Code	HCPCS 82550
Hospital Charge Code	8228855
Hospital Revenue Code	301
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$63.05
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

CK, (Rfx if Elevated) FSI

Facility

$97.00

Service Code	HCPCS 82550
Hospital Charge Code	8228855
Hospital Revenue Code	301
Min. Negotiated Rate	$6.51
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$48.50
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Devoted Health Medicare	$53.35
Rate for Payer: Hawaii Medical Service Association ABD	$9.01
Rate for Payer: Hawaii Medical Service Association Commercial	$8.14
Rate for Payer: Hawaii Medical Service Association Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.46
Rate for Payer: Hawaii Western Management Group Commercial	$6.51
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$48.50
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$48.50
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$9.01
Rate for Payer: UnitedHealthcare Medicare	$48.50
Rate for Payer: University Health Alliance Commercial	$16.84

CLAVICLE FRACTURE PLATE, 7 HOLE, STRAIGHT STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12974365
Hospital Revenue Code	278
Min. Negotiated Rate	$1,339.50
Max. Negotiated Rate	$2,598.63
Rate for Payer: AlohaCare Medicaid	$1,339.50
Rate for Payer: AlohaCare Medicare	$1,339.50
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Devoted Health Medicare	$1,473.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1,339.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Humana Medicare	$1,339.50
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: Kaiser Permanente Medicaid	$1,366.29
Rate for Payer: Kaiser Permanente Medicare	$1,339.50
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: Ohana Health Plan Medicaid	$1,339.50
Rate for Payer: Ohana Health Plan Medicare	$1,339.50
Rate for Payer: UnitedHealthcare Medicare	$1,339.50
Rate for Payer: University Health Alliance Commercial	$1,500.24

CLAVICLE FRACTURE PLATE, 7 HOLE, STRAIGHT STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12974365
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.24
Max. Negotiated Rate	$2,598.63
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: University Health Alliance Commercial	$1,500.24

CLEARANCE OF AIRWAYS CHARGE

Facility

$428.00

Service Code	HCPCS 31720
Hospital Charge Code	8243387
Hospital Revenue Code	761
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

CLEARANCE OF AIRWAYS CHARGE

Facility

$428.00

Service Code	HCPCS 31720
Hospital Charge Code	8243387
Hospital Revenue Code	761
Min. Negotiated Rate	$47.17
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$47.17
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$239.68

clevidipine 50 mg/100 mL RTU vial [HHSC]

Facility

$684.06

Service Code	NDC 10122061110
Hospital Charge Code	2501196
Hospital Revenue Code	250
Min. Negotiated Rate	$581.45
Max. Negotiated Rate	$663.54
Rate for Payer: Cash Price	$444.64
Rate for Payer: Health Management Network Commercial	$581.45
Rate for Payer: Kaiser Permanente Commercial	$615.65
Rate for Payer: MDX Hawaii PPO	$663.54

clevidipine 50 mg/100 mL RTU vial [HHSC]

Facility

$684.06

Service Code	NDC 10122061110
Hospital Charge Code	2501196
Hospital Revenue Code	250
Min. Negotiated Rate	$342.03
Max. Negotiated Rate	$663.54
Rate for Payer: AlohaCare Medicaid	$342.03
Rate for Payer: AlohaCare Medicare	$342.03
Rate for Payer: Cash Price	$444.64
Rate for Payer: Devoted Health Medicare	$376.23
Rate for Payer: Hawaii Medical Service Association Medicare	$342.03
Rate for Payer: Hawaii Western Management Group Commercial	$649.86
Rate for Payer: Health Management Network Commercial	$581.45
Rate for Payer: Humana Medicare	$342.03
Rate for Payer: Kaiser Permanente Commercial	$615.65
Rate for Payer: Kaiser Permanente Medicaid	$348.87
Rate for Payer: Kaiser Permanente Medicare	$342.03
Rate for Payer: MDX Hawaii PPO	$663.54
Rate for Payer: Ohana Health Plan Medicaid	$342.03
Rate for Payer: Ohana Health Plan Medicare	$342.03
Rate for Payer: UnitedHealthcare Medicaid	$410.44
Rate for Payer: UnitedHealthcare Medicare	$342.03
Rate for Payer: University Health Alliance Commercial	$498.61

CLH - SARS CoV-2 (COVID-19) by RT-PCR FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8862888
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$89.50
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$98.45
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$89.50
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$89.50
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$89.50
Rate for Payer: Ohana Health Plan Medicare	$89.50
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

CLH - SARS CoV-2 (COVID-19) by RT-PCR FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8862888
Hospital Revenue Code	306
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

clindamycin 150 mg capsule [HHSC]

Facility

$3.49

Service Code	NDC 68084024301
Hospital Charge Code	2500184
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$3.39
Rate for Payer: AlohaCare Medicaid	$1.75
Rate for Payer: AlohaCare Medicare	$1.75
Rate for Payer: Cash Price	$2.27
Rate for Payer: Devoted Health Medicare	$1.92
Rate for Payer: Hawaii Medical Service Association Medicare	$1.75
Rate for Payer: Hawaii Western Management Group Commercial	$3.32
Rate for Payer: Health Management Network Commercial	$2.97
Rate for Payer: Humana Medicare	$1.75
Rate for Payer: Kaiser Permanente Commercial	$3.14
Rate for Payer: Kaiser Permanente Medicaid	$1.78
Rate for Payer: Kaiser Permanente Medicare	$1.75
Rate for Payer: MDX Hawaii PPO	$3.39
Rate for Payer: Ohana Health Plan Medicaid	$1.75
Rate for Payer: Ohana Health Plan Medicare	$1.75
Rate for Payer: UnitedHealthcare Medicaid	$2.09
Rate for Payer: UnitedHealthcare Medicare	$1.75
Rate for Payer: University Health Alliance Commercial	$2.54

clindamycin 150 mg capsule [HHSC]

Facility

$4.06

Service Code	NDC 00904595961
Hospital Charge Code	2500184
Hospital Revenue Code	250
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$3.94
Rate for Payer: AlohaCare Medicaid	$2.03
Rate for Payer: AlohaCare Medicare	$2.03
Rate for Payer: Cash Price	$2.64
Rate for Payer: Devoted Health Medicare	$2.23
Rate for Payer: Hawaii Medical Service Association Medicare	$2.03
Rate for Payer: Hawaii Western Management Group Commercial	$3.86
Rate for Payer: Health Management Network Commercial	$3.45
Rate for Payer: Humana Medicare	$2.03
Rate for Payer: Kaiser Permanente Commercial	$3.65
Rate for Payer: Kaiser Permanente Medicaid	$2.07
Rate for Payer: Kaiser Permanente Medicare	$2.03
Rate for Payer: MDX Hawaii PPO	$3.94
Rate for Payer: Ohana Health Plan Medicaid	$2.03
Rate for Payer: Ohana Health Plan Medicare	$2.03
Rate for Payer: UnitedHealthcare Medicaid	$2.44
Rate for Payer: UnitedHealthcare Medicare	$2.03
Rate for Payer: University Health Alliance Commercial	$2.96

clindamycin 150 mg capsule [HHSC]

Facility

$4.06

Service Code	NDC 00904595961
Hospital Charge Code	2500184
Hospital Revenue Code	250
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$3.94
Rate for Payer: Cash Price	$2.64
Rate for Payer: Health Management Network Commercial	$3.45
Rate for Payer: Kaiser Permanente Commercial	$3.65
Rate for Payer: MDX Hawaii PPO	$3.94

clindamycin 150 mg capsule [HHSC]

Facility

$3.49

Service Code	NDC 68084024301
Hospital Charge Code	2500184
Hospital Revenue Code	250
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$3.39
Rate for Payer: Cash Price	$2.27
Rate for Payer: Health Management Network Commercial	$2.97
Rate for Payer: Kaiser Permanente Commercial	$3.14
Rate for Payer: MDX Hawaii PPO	$3.39

clindamycin 300 mg capsule [HHSC]

Facility

$20.67

Service Code	NDC 65862018601
Hospital Charge Code	2500186
Hospital Revenue Code	250
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$20.05
Rate for Payer: Cash Price	$13.44
Rate for Payer: Health Management Network Commercial	$17.57
Rate for Payer: Kaiser Permanente Commercial	$18.60
Rate for Payer: MDX Hawaii PPO	$20.05

clindamycin 300 mg capsule [HHSC]

Facility

$20.67

Service Code	NDC 42571025201
Hospital Charge Code	2500186
Hospital Revenue Code	250
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$20.05
Rate for Payer: AlohaCare Medicaid	$10.34
Rate for Payer: AlohaCare Medicare	$10.34
Rate for Payer: Cash Price	$13.44
Rate for Payer: Devoted Health Medicare	$11.37
Rate for Payer: Hawaii Medical Service Association Medicare	$10.34
Rate for Payer: Hawaii Western Management Group Commercial	$19.64
Rate for Payer: Health Management Network Commercial	$17.57
Rate for Payer: Humana Medicare	$10.34
Rate for Payer: Kaiser Permanente Commercial	$18.60
Rate for Payer: Kaiser Permanente Medicaid	$10.54
Rate for Payer: Kaiser Permanente Medicare	$10.34
Rate for Payer: MDX Hawaii PPO	$20.05
Rate for Payer: Ohana Health Plan Medicaid	$10.34
Rate for Payer: Ohana Health Plan Medicare	$10.34
Rate for Payer: UnitedHealthcare Medicaid	$12.40
Rate for Payer: UnitedHealthcare Medicare	$10.34
Rate for Payer: University Health Alliance Commercial	$15.07

clindamycin 300 mg capsule [HHSC]

Facility

$20.67

Service Code	NDC 63304069301
Hospital Charge Code	2500186
Hospital Revenue Code	250
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$20.05
Rate for Payer: AlohaCare Medicaid	$10.34
Rate for Payer: AlohaCare Medicare	$10.34
Rate for Payer: Cash Price	$13.44
Rate for Payer: Devoted Health Medicare	$11.37
Rate for Payer: Hawaii Medical Service Association Medicare	$10.34
Rate for Payer: Hawaii Western Management Group Commercial	$19.64
Rate for Payer: Health Management Network Commercial	$17.57
Rate for Payer: Humana Medicare	$10.34
Rate for Payer: Kaiser Permanente Commercial	$18.60
Rate for Payer: Kaiser Permanente Medicaid	$10.54
Rate for Payer: Kaiser Permanente Medicare	$10.34
Rate for Payer: MDX Hawaii PPO	$20.05
Rate for Payer: Ohana Health Plan Medicaid	$10.34
Rate for Payer: Ohana Health Plan Medicare	$10.34
Rate for Payer: UnitedHealthcare Medicaid	$12.40
Rate for Payer: UnitedHealthcare Medicare	$10.34
Rate for Payer: University Health Alliance Commercial	$15.07

clindamycin 300 mg capsule [HHSC]

Facility

$20.67

Service Code	NDC 65862018601
Hospital Charge Code	2500186
Hospital Revenue Code	250
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$20.05
Rate for Payer: AlohaCare Medicaid	$10.34
Rate for Payer: AlohaCare Medicare	$10.34
Rate for Payer: Cash Price	$13.44
Rate for Payer: Devoted Health Medicare	$11.37
Rate for Payer: Hawaii Medical Service Association Medicare	$10.34
Rate for Payer: Hawaii Western Management Group Commercial	$19.64
Rate for Payer: Health Management Network Commercial	$17.57
Rate for Payer: Humana Medicare	$10.34
Rate for Payer: Kaiser Permanente Commercial	$18.60
Rate for Payer: Kaiser Permanente Medicaid	$10.54
Rate for Payer: Kaiser Permanente Medicare	$10.34
Rate for Payer: MDX Hawaii PPO	$20.05
Rate for Payer: Ohana Health Plan Medicaid	$10.34
Rate for Payer: Ohana Health Plan Medicare	$10.34
Rate for Payer: UnitedHealthcare Medicaid	$12.40
Rate for Payer: UnitedHealthcare Medicare	$10.34
Rate for Payer: University Health Alliance Commercial	$15.07

clindamycin 300 mg capsule [HHSC]

Facility

$20.67

Service Code	NDC 42571025201
Hospital Charge Code	2500186
Hospital Revenue Code	250
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$20.05
Rate for Payer: Cash Price	$13.44
Rate for Payer: Health Management Network Commercial	$17.57
Rate for Payer: Kaiser Permanente Commercial	$18.60
Rate for Payer: MDX Hawaii PPO	$20.05

clindamycin 300 mg capsule [HHSC]

Facility

$7.91

Service Code	NDC 50268018515
Hospital Charge Code	2500186
Hospital Revenue Code	250
Min. Negotiated Rate	$6.72
Max. Negotiated Rate	$7.67
Rate for Payer: Cash Price	$5.14
Rate for Payer: Health Management Network Commercial	$6.72
Rate for Payer: Kaiser Permanente Commercial	$7.12
Rate for Payer: MDX Hawaii PPO	$7.67

Know your out-of-pocket cost for care.

All Charges