Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

acetaminophen 120 mg suppository [HHSC]

Facility

$3.00

Service Code	NDC 45802073233
Hospital Charge Code	2500001
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

acetaminophen 325 mg/10.15 mL susp [HHSC]

Facility

$6.04

Service Code	NDC 68094033061
Hospital Charge Code	2501128
Hospital Revenue Code	250
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$5.86
Rate for Payer: Cash Price	$3.93
Rate for Payer: Health Management Network Commercial	$5.13
Rate for Payer: Kaiser Permanente Commercial	$5.44
Rate for Payer: MDX Hawaii PPO	$5.86

acetaminophen 325 mg/10.15 mL susp [HHSC]

Facility

$6.04

Service Code	NDC 68094033061
Hospital Charge Code	2501128
Hospital Revenue Code	250
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$5.86
Rate for Payer: AlohaCare Medicaid	$3.02
Rate for Payer: AlohaCare Medicare	$3.02
Rate for Payer: Cash Price	$3.93
Rate for Payer: Devoted Health Medicare	$3.32
Rate for Payer: Hawaii Medical Service Association Medicare	$3.02
Rate for Payer: Hawaii Western Management Group Commercial	$5.74
Rate for Payer: Health Management Network Commercial	$5.13
Rate for Payer: Humana Medicare	$3.02
Rate for Payer: Kaiser Permanente Commercial	$5.44
Rate for Payer: Kaiser Permanente Medicaid	$3.08
Rate for Payer: Kaiser Permanente Medicare	$3.02
Rate for Payer: MDX Hawaii PPO	$5.86
Rate for Payer: Ohana Health Plan Medicaid	$3.02
Rate for Payer: Ohana Health Plan Medicare	$3.02
Rate for Payer: UnitedHealthcare Medicaid	$3.62
Rate for Payer: UnitedHealthcare Medicare	$3.02
Rate for Payer: University Health Alliance Commercial	$4.40

acetaminophen 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536132701
Hospital Charge Code	2500005
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

acetaminophen 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399102503
Hospital Charge Code	2500005
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904677361
Hospital Charge Code	2500005
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 71399102503
Hospital Charge Code	2500005
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

acetaminophen 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00536132701
Hospital Charge Code	2500005
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen 325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904677361
Hospital Charge Code	2500005
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

acetaminophen 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 57896020401
Hospital Charge Code	2500006
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904673061
Hospital Charge Code	2500006
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904672059
Hospital Charge Code	2500006
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

acetaminophen 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904672059
Hospital Charge Code	2500006
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

acetaminophen 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904673061
Hospital Charge Code	2500006
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

acetaminophen 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 57896020401
Hospital Charge Code	2500006
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

acetaminophen 650 mg suppository [HHSC]

Facility

$3.70

Service Code	NDC 45802073030
Hospital Charge Code	2500007
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.59
Rate for Payer: AlohaCare Medicaid	$1.85
Rate for Payer: AlohaCare Medicare	$1.85
Rate for Payer: Cash Price	$2.41
Rate for Payer: Devoted Health Medicare	$2.04
Rate for Payer: Hawaii Medical Service Association Medicare	$1.85
Rate for Payer: Hawaii Western Management Group Commercial	$3.52
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Humana Medicare	$1.85
Rate for Payer: Kaiser Permanente Commercial	$3.33
Rate for Payer: Kaiser Permanente Medicaid	$1.89
Rate for Payer: Kaiser Permanente Medicare	$1.85
Rate for Payer: MDX Hawaii PPO	$3.59
Rate for Payer: Ohana Health Plan Medicaid	$1.85
Rate for Payer: Ohana Health Plan Medicare	$1.85
Rate for Payer: UnitedHealthcare Medicaid	$2.22
Rate for Payer: UnitedHealthcare Medicare	$1.85
Rate for Payer: University Health Alliance Commercial	$2.70

acetaminophen 650 mg suppository [HHSC]

Facility

$3.70

Service Code	NDC 45802073030
Hospital Charge Code	2500007
Hospital Revenue Code	250
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$3.59
Rate for Payer: Cash Price	$2.41
Rate for Payer: Health Management Network Commercial	$3.15
Rate for Payer: Kaiser Permanente Commercial	$3.33
Rate for Payer: MDX Hawaii PPO	$3.59

acetaminophen 650 mg suppository [HHSC]

Facility

$3.30

Service Code	NDC 45802073032
Hospital Charge Code	2500007
Hospital Revenue Code	250
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$3.20
Rate for Payer: AlohaCare Medicaid	$1.65
Rate for Payer: AlohaCare Medicare	$1.65
Rate for Payer: Cash Price	$2.14
Rate for Payer: Devoted Health Medicare	$1.81
Rate for Payer: Hawaii Medical Service Association Medicare	$1.65
Rate for Payer: Hawaii Western Management Group Commercial	$3.13
Rate for Payer: Health Management Network Commercial	$2.81
Rate for Payer: Humana Medicare	$1.65
Rate for Payer: Kaiser Permanente Commercial	$2.97
Rate for Payer: Kaiser Permanente Medicaid	$1.68
Rate for Payer: Kaiser Permanente Medicare	$1.65
Rate for Payer: MDX Hawaii PPO	$3.20
Rate for Payer: Ohana Health Plan Medicaid	$1.65
Rate for Payer: Ohana Health Plan Medicare	$1.65
Rate for Payer: UnitedHealthcare Medicaid	$1.98
Rate for Payer: UnitedHealthcare Medicare	$1.65
Rate for Payer: University Health Alliance Commercial	$2.41

acetaminophen 650 mg suppository [HHSC]

Facility

$3.30

Service Code	NDC 45802073032
Hospital Charge Code	2500007
Hospital Revenue Code	250
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Management Network Commercial	$2.81
Rate for Payer: Kaiser Permanente Commercial	$2.97
Rate for Payer: MDX Hawaii PPO	$3.20

Acetaminophen Level FSI

Facility

$1,384.00

Service Code	HCPCS 80143
Hospital Charge Code	8117760
Hospital Revenue Code	301
Min. Negotiated Rate	$1,176.40
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$899.60
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: MDX Hawaii PPO	$1,342.48

Acetaminophen Level FSI

Facility

$1,384.00

Service Code	HCPCS 80143
Hospital Charge Code	8117760
Hospital Revenue Code	301
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$1,342.48
Rate for Payer: AlohaCare Medicaid	$692.00
Rate for Payer: AlohaCare Medicare	$692.00
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Devoted Health Medicare	$761.20
Rate for Payer: Hawaii Medical Service Association ABD	$18.92
Rate for Payer: Hawaii Medical Service Association Commercial	$23.30
Rate for Payer: Hawaii Medical Service Association Medicare	$692.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.87
Rate for Payer: Hawaii Western Management Group Commercial	$18.64
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Humana Medicare	$692.00
Rate for Payer: Kaiser Permanente Commercial	$1,245.60
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: Kaiser Permanente Medicare	$692.00
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: Ohana Health Plan Medicaid	$692.00
Rate for Payer: Ohana Health Plan Medicare	$692.00
Rate for Payer: UnitedHealthcare Medicaid	$11.18
Rate for Payer: UnitedHealthcare Medicare	$692.00
Rate for Payer: University Health Alliance Commercial	$775.04

Acetone Qualitative FSI

Facility

$55.00

Service Code	HCPCS 82009
Hospital Charge Code	8404546
Hospital Revenue Code	301
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association ABD	$6.25
Rate for Payer: Hawaii Medical Service Association Commercial	$5.65
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.56
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicaid	$6.25
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$11.67

Acetone Qualitative FSI

Facility

$55.00

Service Code	HCPCS 82009
Hospital Charge Code	8404546
Hospital Revenue Code	301
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

Acetone, Qualitative FSI

Facility

$55.00

Service Code	HCPCS 82009
Hospital Charge Code	9078871
Hospital Revenue Code	301
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association ABD	$6.25
Rate for Payer: Hawaii Medical Service Association Commercial	$5.65
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.56
Rate for Payer: Hawaii Western Management Group Commercial	$4.52
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicaid	$6.25
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$11.67

Acetone, Qualitative FSI

Facility

$55.00

Service Code	HCPCS 82009
Hospital Charge Code	9078871
Hospital Revenue Code	301
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

Know your out-of-pocket cost for care.

All Charges