Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

apixaban 2.5 mg tablet [HHSC]

Facility

$65.03

Service Code	NDC 00003089321
Hospital Charge Code	2500064
Hospital Revenue Code	250
Min. Negotiated Rate	$55.28
Max. Negotiated Rate	$63.08
Rate for Payer: Cash Price	$42.27
Rate for Payer: Health Management Network Commercial	$55.28
Rate for Payer: Kaiser Permanente Commercial	$58.53
Rate for Payer: MDX Hawaii PPO	$63.08

apixaban 5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089431
Hospital Charge Code	2500065
Hospital Revenue Code	250
Min. Negotiated Rate	$25.25
Max. Negotiated Rate	$48.98
Rate for Payer: AlohaCare Medicaid	$25.25
Rate for Payer: AlohaCare Medicare	$25.25
Rate for Payer: Cash Price	$32.83
Rate for Payer: Devoted Health Medicare	$27.77
Rate for Payer: Hawaii Medical Service Association Medicare	$25.25
Rate for Payer: Hawaii Western Management Group Commercial	$47.98
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Humana Medicare	$25.25
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: Kaiser Permanente Medicaid	$25.75
Rate for Payer: Kaiser Permanente Medicare	$25.25
Rate for Payer: MDX Hawaii PPO	$48.98
Rate for Payer: Ohana Health Plan Medicaid	$25.25
Rate for Payer: Ohana Health Plan Medicare	$25.25
Rate for Payer: UnitedHealthcare Medicaid	$30.30
Rate for Payer: UnitedHealthcare Medicare	$25.25
Rate for Payer: University Health Alliance Commercial	$36.81

apixaban 5 mg tablet [HHSC]

Facility

$50.50

Service Code	NDC 00003089431
Hospital Charge Code	2500065
Hospital Revenue Code	250
Min. Negotiated Rate	$42.92
Max. Negotiated Rate	$48.98
Rate for Payer: Cash Price	$32.83
Rate for Payer: Health Management Network Commercial	$42.92
Rate for Payer: Kaiser Permanente Commercial	$45.45
Rate for Payer: MDX Hawaii PPO	$48.98

APPENDIX PROCEDURES WITH CC

Facility

$31,689.57

Service Code	MSDRG 398
Min. Negotiated Rate	$31,689.57
Max. Negotiated Rate	$31,689.57
Rate for Payer: Hawaii Medical Service Association Commercial	$31,689.57

APPENDIX PROCEDURES WITH MCC

Facility

$34,320.50

Service Code	MSDRG 397
Min. Negotiated Rate	$34,320.50
Max. Negotiated Rate	$34,320.50
Rate for Payer: Hawaii Medical Service Association Commercial	$34,320.50

APPENDIX PROCEDURES WITHOUT CC/MCC

Facility

$23,654.60

Service Code	MSDRG 399
Min. Negotiated Rate	$23,654.60
Max. Negotiated Rate	$23,654.60
Rate for Payer: Hawaii Medical Service Association Commercial	$23,654.60

AQUILEX FLUID CONTROL SYSTEM COMPLETE TUBE SET

Facility

$540.00

Hospital Charge Code	9390101
Hospital Revenue Code	272
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$523.80
Rate for Payer: Cash Price	$351.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: MDX Hawaii PPO	$523.80

AQUILEX FLUID CONTROL SYSTEM COMPLETE TUBE SET

Facility

$540.00

Hospital Charge Code	9390101
Hospital Revenue Code	272
Min. Negotiated Rate	$270.00
Max. Negotiated Rate	$523.80
Rate for Payer: AlohaCare Medicaid	$270.00
Rate for Payer: AlohaCare Medicare	$270.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Devoted Health Medicare	$297.00
Rate for Payer: Hawaii Medical Service Association Medicare	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$513.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Humana Medicare	$270.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: Kaiser Permanente Medicaid	$275.40
Rate for Payer: Kaiser Permanente Medicare	$270.00
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: Ohana Health Plan Medicaid	$270.00
Rate for Payer: Ohana Health Plan Medicare	$270.00
Rate for Payer: UnitedHealthcare Medicare	$270.00
Rate for Payer: University Health Alliance Commercial	$393.61

ARIPiprazole 15 mg tablet [HHSC]

Facility

$147.34

Service Code	NDC 60687019121
Hospital Charge Code	2500067
Hospital Revenue Code	250
Min. Negotiated Rate	$125.24
Max. Negotiated Rate	$142.92
Rate for Payer: Cash Price	$95.77
Rate for Payer: Health Management Network Commercial	$125.24
Rate for Payer: Kaiser Permanente Commercial	$132.61
Rate for Payer: MDX Hawaii PPO	$142.92

ARIPiprazole 15 mg tablet [HHSC]

Facility

$152.22

Service Code	NDC 62332010031
Hospital Charge Code	2500067
Hospital Revenue Code	250
Min. Negotiated Rate	$129.39
Max. Negotiated Rate	$147.65
Rate for Payer: Cash Price	$98.94
Rate for Payer: Health Management Network Commercial	$129.39
Rate for Payer: Kaiser Permanente Commercial	$137.00
Rate for Payer: MDX Hawaii PPO	$147.65

ARIPiprazole 15 mg tablet [HHSC]

Facility

$147.34

Service Code	NDC 60687019121
Hospital Charge Code	2500067
Hospital Revenue Code	250
Min. Negotiated Rate	$73.67
Max. Negotiated Rate	$142.92
Rate for Payer: AlohaCare Medicaid	$73.67
Rate for Payer: AlohaCare Medicare	$73.67
Rate for Payer: Cash Price	$95.77
Rate for Payer: Devoted Health Medicare	$81.04
Rate for Payer: Hawaii Medical Service Association Medicare	$73.67
Rate for Payer: Hawaii Western Management Group Commercial	$139.97
Rate for Payer: Health Management Network Commercial	$125.24
Rate for Payer: Humana Medicare	$73.67
Rate for Payer: Kaiser Permanente Commercial	$132.61
Rate for Payer: Kaiser Permanente Medicaid	$75.14
Rate for Payer: Kaiser Permanente Medicare	$73.67
Rate for Payer: MDX Hawaii PPO	$142.92
Rate for Payer: Ohana Health Plan Medicaid	$73.67
Rate for Payer: Ohana Health Plan Medicare	$73.67
Rate for Payer: UnitedHealthcare Medicaid	$88.40
Rate for Payer: UnitedHealthcare Medicare	$73.67
Rate for Payer: University Health Alliance Commercial	$107.40

ARIPiprazole 15 mg tablet [HHSC]

Facility

$151.91

Service Code	NDC 62332010030
Hospital Charge Code	2500067
Hospital Revenue Code	250
Min. Negotiated Rate	$75.95
Max. Negotiated Rate	$147.35
Rate for Payer: AlohaCare Medicaid	$75.95
Rate for Payer: AlohaCare Medicare	$75.95
Rate for Payer: Cash Price	$98.74
Rate for Payer: Devoted Health Medicare	$83.55
Rate for Payer: Hawaii Medical Service Association Medicare	$75.95
Rate for Payer: Hawaii Western Management Group Commercial	$144.31
Rate for Payer: Health Management Network Commercial	$129.12
Rate for Payer: Humana Medicare	$75.95
Rate for Payer: Kaiser Permanente Commercial	$136.72
Rate for Payer: Kaiser Permanente Medicaid	$77.47
Rate for Payer: Kaiser Permanente Medicare	$75.95
Rate for Payer: MDX Hawaii PPO	$147.35
Rate for Payer: Ohana Health Plan Medicaid	$75.95
Rate for Payer: Ohana Health Plan Medicare	$75.95
Rate for Payer: UnitedHealthcare Medicaid	$91.15
Rate for Payer: UnitedHealthcare Medicare	$75.95
Rate for Payer: University Health Alliance Commercial	$110.73

ARIPiprazole 15 mg tablet [HHSC]

Facility

$151.91

Service Code	NDC 62332010030
Hospital Charge Code	2500067
Hospital Revenue Code	250
Min. Negotiated Rate	$129.12
Max. Negotiated Rate	$147.35
Rate for Payer: Cash Price	$98.74
Rate for Payer: Health Management Network Commercial	$129.12
Rate for Payer: Kaiser Permanente Commercial	$136.72
Rate for Payer: MDX Hawaii PPO	$147.35

ARIPiprazole 15 mg tablet [HHSC]

Facility

$152.22

Service Code	NDC 62332010031
Hospital Charge Code	2500067
Hospital Revenue Code	250
Min. Negotiated Rate	$76.11
Max. Negotiated Rate	$147.65
Rate for Payer: AlohaCare Medicaid	$76.11
Rate for Payer: AlohaCare Medicare	$76.11
Rate for Payer: Cash Price	$98.94
Rate for Payer: Devoted Health Medicare	$83.72
Rate for Payer: Hawaii Medical Service Association Medicare	$76.11
Rate for Payer: Hawaii Western Management Group Commercial	$144.61
Rate for Payer: Health Management Network Commercial	$129.39
Rate for Payer: Humana Medicare	$76.11
Rate for Payer: Kaiser Permanente Commercial	$137.00
Rate for Payer: Kaiser Permanente Medicaid	$77.63
Rate for Payer: Kaiser Permanente Medicare	$76.11
Rate for Payer: MDX Hawaii PPO	$147.65
Rate for Payer: Ohana Health Plan Medicaid	$76.11
Rate for Payer: Ohana Health Plan Medicare	$76.11
Rate for Payer: UnitedHealthcare Medicaid	$91.33
Rate for Payer: UnitedHealthcare Medicare	$76.11
Rate for Payer: University Health Alliance Commercial	$110.95

ARIPiprazole 5 mg tablet [HHSC]

Facility

$151.91

Service Code	NDC 62332009830
Hospital Charge Code	2500069
Hospital Revenue Code	250
Min. Negotiated Rate	$75.95
Max. Negotiated Rate	$147.35
Rate for Payer: AlohaCare Medicaid	$75.95
Rate for Payer: AlohaCare Medicare	$75.95
Rate for Payer: Cash Price	$98.74
Rate for Payer: Devoted Health Medicare	$83.55
Rate for Payer: Hawaii Medical Service Association Medicare	$75.95
Rate for Payer: Hawaii Western Management Group Commercial	$144.31
Rate for Payer: Health Management Network Commercial	$129.12
Rate for Payer: Humana Medicare	$75.95
Rate for Payer: Kaiser Permanente Commercial	$136.72
Rate for Payer: Kaiser Permanente Medicaid	$77.47
Rate for Payer: Kaiser Permanente Medicare	$75.95
Rate for Payer: MDX Hawaii PPO	$147.35
Rate for Payer: Ohana Health Plan Medicaid	$75.95
Rate for Payer: Ohana Health Plan Medicare	$75.95
Rate for Payer: UnitedHealthcare Medicaid	$91.15
Rate for Payer: UnitedHealthcare Medicare	$75.95
Rate for Payer: University Health Alliance Commercial	$110.73

ARIPiprazole 5 mg tablet [HHSC]

Facility

$151.91

Service Code	NDC 62332009830
Hospital Charge Code	2500069
Hospital Revenue Code	250
Min. Negotiated Rate	$129.12
Max. Negotiated Rate	$147.35
Rate for Payer: Cash Price	$98.74
Rate for Payer: Health Management Network Commercial	$129.12
Rate for Payer: Kaiser Permanente Commercial	$136.72
Rate for Payer: MDX Hawaii PPO	$147.35

ARIPiprazole 5 mg tablet [HHSC]

Facility

$152.22

Service Code	NDC 62332009831
Hospital Charge Code	2500069
Hospital Revenue Code	250
Min. Negotiated Rate	$76.11
Max. Negotiated Rate	$147.65
Rate for Payer: AlohaCare Medicaid	$76.11
Rate for Payer: AlohaCare Medicare	$76.11
Rate for Payer: Cash Price	$98.94
Rate for Payer: Devoted Health Medicare	$83.72
Rate for Payer: Hawaii Medical Service Association Medicare	$76.11
Rate for Payer: Hawaii Western Management Group Commercial	$144.61
Rate for Payer: Health Management Network Commercial	$129.39
Rate for Payer: Humana Medicare	$76.11
Rate for Payer: Kaiser Permanente Commercial	$137.00
Rate for Payer: Kaiser Permanente Medicaid	$77.63
Rate for Payer: Kaiser Permanente Medicare	$76.11
Rate for Payer: MDX Hawaii PPO	$147.65
Rate for Payer: Ohana Health Plan Medicaid	$76.11
Rate for Payer: Ohana Health Plan Medicare	$76.11
Rate for Payer: UnitedHealthcare Medicaid	$91.33
Rate for Payer: UnitedHealthcare Medicare	$76.11
Rate for Payer: University Health Alliance Commercial	$110.95

ARIPiprazole 5 mg tablet [HHSC]

Facility

$152.22

Service Code	NDC 62332009831
Hospital Charge Code	2500069
Hospital Revenue Code	250
Min. Negotiated Rate	$129.39
Max. Negotiated Rate	$147.65
Rate for Payer: Cash Price	$98.94
Rate for Payer: Health Management Network Commercial	$129.39
Rate for Payer: Kaiser Permanente Commercial	$137.00
Rate for Payer: MDX Hawaii PPO	$147.65

ARIPiprazole 5 mg tablet [HHSC]

Facility

$152.37

Service Code	NDC 27241005203
Hospital Charge Code	2500069
Hospital Revenue Code	250
Min. Negotiated Rate	$76.19
Max. Negotiated Rate	$147.80
Rate for Payer: AlohaCare Medicaid	$76.19
Rate for Payer: AlohaCare Medicare	$76.19
Rate for Payer: Cash Price	$99.04
Rate for Payer: Devoted Health Medicare	$83.80
Rate for Payer: Hawaii Medical Service Association Medicare	$76.19
Rate for Payer: Hawaii Western Management Group Commercial	$144.75
Rate for Payer: Health Management Network Commercial	$129.51
Rate for Payer: Humana Medicare	$76.19
Rate for Payer: Kaiser Permanente Commercial	$137.13
Rate for Payer: Kaiser Permanente Medicaid	$77.71
Rate for Payer: Kaiser Permanente Medicare	$76.19
Rate for Payer: MDX Hawaii PPO	$147.80
Rate for Payer: Ohana Health Plan Medicaid	$76.19
Rate for Payer: Ohana Health Plan Medicare	$76.19
Rate for Payer: UnitedHealthcare Medicaid	$91.42
Rate for Payer: UnitedHealthcare Medicare	$76.19
Rate for Payer: University Health Alliance Commercial	$111.06

ARIPiprazole 5 mg tablet [HHSC]

Facility

$152.37

Service Code	NDC 27241005203
Hospital Charge Code	2500069
Hospital Revenue Code	250
Min. Negotiated Rate	$129.51
Max. Negotiated Rate	$147.80
Rate for Payer: Cash Price	$99.04
Rate for Payer: Health Management Network Commercial	$129.51
Rate for Payer: Kaiser Permanente Commercial	$137.13
Rate for Payer: MDX Hawaii PPO	$147.80

Arterial Puncture (Blood Gas) Nursing

Facility

$255.00

Service Code	HCPCS 36600
Hospital Charge Code	11937722
Hospital Revenue Code	300
Min. Negotiated Rate	$15.16
Max. Negotiated Rate	$247.35
Rate for Payer: AlohaCare Medicaid	$127.50
Rate for Payer: AlohaCare Medicare	$127.50
Rate for Payer: Cash Price	$165.75
Rate for Payer: Cash Price	$165.75
Rate for Payer: Devoted Health Medicare	$140.25
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$127.50
Rate for Payer: Hawaii Western Management Group Commercial	$242.25
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Humana Medicare	$127.50
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$130.05
Rate for Payer: Kaiser Permanente Medicare	$127.50
Rate for Payer: MDX Hawaii PPO	$247.35
Rate for Payer: Ohana Health Plan Medicaid	$127.50
Rate for Payer: Ohana Health Plan Medicare	$127.50
Rate for Payer: UnitedHealthcare Medicaid	$15.16
Rate for Payer: UnitedHealthcare Medicare	$127.50
Rate for Payer: University Health Alliance Commercial	$142.80

Arterial Puncture (Blood Gas) Nursing

Facility

$255.00

Service Code	HCPCS 36600
Hospital Charge Code	11937722
Hospital Revenue Code	300
Min. Negotiated Rate	$216.75
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$165.75
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$247.35

aspirin 81 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 63739043401
Hospital Charge Code	2500074
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

aspirin 81 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904404073
Hospital Charge Code	2500074
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

aspirin 81 mg chewable tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904404073
Hospital Charge Code	2500074
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

Know your out-of-pocket cost for care.

All Charges