Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

carBAMazepine 200 mg tablet [HHSC]

Facility

$8.89

Service Code	NDC 60505018300
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$8.62
Rate for Payer: Cash Price	$5.78
Rate for Payer: Health Management Network Commercial	$7.56
Rate for Payer: Kaiser Permanente Commercial	$8.00
Rate for Payer: MDX Hawaii PPO	$8.62

carBAMazepine 200 mg tablet [HHSC]

Facility

$9.14

Service Code	NDC 68084044401
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$7.77
Max. Negotiated Rate	$8.87
Rate for Payer: Cash Price	$5.94
Rate for Payer: Health Management Network Commercial	$7.77
Rate for Payer: Kaiser Permanente Commercial	$8.23
Rate for Payer: MDX Hawaii PPO	$8.87

carBAMazepine 200 mg tablet [HHSC]

Facility

$8.89

Service Code	NDC 75834022101
Hospital Charge Code	2500142
Hospital Revenue Code	250
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$8.62
Rate for Payer: AlohaCare Medicaid	$4.45
Rate for Payer: AlohaCare Medicare	$4.45
Rate for Payer: Cash Price	$5.78
Rate for Payer: Devoted Health Medicare	$4.89
Rate for Payer: Hawaii Medical Service Association Medicare	$4.45
Rate for Payer: Hawaii Western Management Group Commercial	$8.45
Rate for Payer: Health Management Network Commercial	$7.56
Rate for Payer: Humana Medicare	$4.45
Rate for Payer: Kaiser Permanente Commercial	$8.00
Rate for Payer: Kaiser Permanente Medicaid	$4.53
Rate for Payer: Kaiser Permanente Medicare	$4.45
Rate for Payer: MDX Hawaii PPO	$8.62
Rate for Payer: Ohana Health Plan Medicaid	$4.45
Rate for Payer: Ohana Health Plan Medicare	$4.45
Rate for Payer: UnitedHealthcare Medicaid	$5.33
Rate for Payer: UnitedHealthcare Medicare	$4.45
Rate for Payer: University Health Alliance Commercial	$6.48

Carbamazepine/Tegretol FSI

Facility

$166.00

Service Code	HCPCS 82436
Hospital Charge Code	8117873
Hospital Revenue Code	301
Min. Negotiated Rate	$5.75
Max. Negotiated Rate	$161.02
Rate for Payer: AlohaCare Medicaid	$83.00
Rate for Payer: AlohaCare Medicare	$83.00
Rate for Payer: Cash Price	$107.90
Rate for Payer: Cash Price	$107.90
Rate for Payer: Devoted Health Medicare	$91.30
Rate for Payer: Hawaii Medical Service Association ABD	$6.95
Rate for Payer: Hawaii Medical Service Association Commercial	$7.19
Rate for Payer: Hawaii Medical Service Association Medicare	$83.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.30
Rate for Payer: Hawaii Western Management Group Commercial	$5.75
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Humana Medicare	$83.00
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: Kaiser Permanente Medicaid	$84.66
Rate for Payer: Kaiser Permanente Medicare	$83.00
Rate for Payer: MDX Hawaii PPO	$161.02
Rate for Payer: Ohana Health Plan Medicaid	$83.00
Rate for Payer: Ohana Health Plan Medicare	$83.00
Rate for Payer: UnitedHealthcare Medicaid	$6.95
Rate for Payer: UnitedHealthcare Medicare	$83.00
Rate for Payer: University Health Alliance Commercial	$12.99

Carbamazepine/Tegretol FSI

Facility

$166.00

Service Code	HCPCS 82436
Hospital Charge Code	8117873
Hospital Revenue Code	301
Min. Negotiated Rate	$141.10
Max. Negotiated Rate	$161.02
Rate for Payer: Cash Price	$107.90
Rate for Payer: Health Management Network Commercial	$141.10
Rate for Payer: Kaiser Permanente Commercial	$149.40
Rate for Payer: MDX Hawaii PPO	$161.02

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.00

Service Code	NDC 42037010478
Hospital Charge Code	2500143
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

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.00

Service Code	NDC 00904662735
Hospital Charge Code	2500143
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

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.00

Service Code	NDC 46122055705
Hospital Charge Code	2500143
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

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.72

Service Code	NDC 42037010479
Hospital Charge Code	2500143
Hospital Revenue Code	250
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$3.61
Rate for Payer: AlohaCare Medicaid	$1.86
Rate for Payer: AlohaCare Medicare	$1.86
Rate for Payer: Cash Price	$2.42
Rate for Payer: Devoted Health Medicare	$2.05
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
Rate for Payer: Hawaii Western Management Group Commercial	$3.53
Rate for Payer: Health Management Network Commercial	$3.16
Rate for Payer: Humana Medicare	$1.86
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: Kaiser Permanente Medicaid	$1.90
Rate for Payer: Kaiser Permanente Medicare	$1.86
Rate for Payer: MDX Hawaii PPO	$3.61
Rate for Payer: Ohana Health Plan Medicaid	$1.86
Rate for Payer: Ohana Health Plan Medicare	$1.86
Rate for Payer: UnitedHealthcare Medicaid	$2.23
Rate for Payer: UnitedHealthcare Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$2.71

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.72

Service Code	NDC 42037010479
Hospital Charge Code	2500143
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$3.61
Rate for Payer: Cash Price	$2.42
Rate for Payer: Health Management Network Commercial	$3.16
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: MDX Hawaii PPO	$3.61

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.00

Service Code	NDC 46122055705
Hospital Charge Code	2500143
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

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.00

Service Code	NDC 42037010478
Hospital Charge Code	2500143
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

carbamide peroxide 6.5% drops [HHSC]

Facility

$3.00

Service Code	NDC 00904662735
Hospital Charge Code	2500143
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

carbidopa-levodopa 25/100 mg tablet [HHSC]

Facility

$4.56

Service Code	HCPCS J8499
Hospital Charge Code	2500145
Hospital Revenue Code	636
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$4.42
Rate for Payer: AlohaCare Medicaid	$2.28
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$2.96
Rate for Payer: Devoted Health Medicare	$2.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$4.33
Rate for Payer: Health Management Network Commercial	$3.88
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$4.10
Rate for Payer: Kaiser Permanente Medicaid	$2.33
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$4.42
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicaid	$2.74
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$3.32

carbidopa-levodopa 25/100 mg tablet [HHSC]

Facility

$4.56

Service Code	HCPCS J8499
Hospital Charge Code	2500145
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$4.42
Rate for Payer: Cash Price	$2.96
Rate for Payer: Health Management Network Commercial	$3.88
Rate for Payer: Kaiser Permanente Commercial	$4.10
Rate for Payer: MDX Hawaii PPO	$4.42

carboxymethylcellulos 0.5% ophth 15 mL [HHSC]

Facility

$55.80

Service Code	NDC 50268006815
Hospital Charge Code	2500603
Hospital Revenue Code	250
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$54.13
Rate for Payer: Cash Price	$36.27
Rate for Payer: Health Management Network Commercial	$47.43
Rate for Payer: Kaiser Permanente Commercial	$50.22
Rate for Payer: MDX Hawaii PPO	$54.13

carboxymethylcellulos 0.5% ophth 15 mL [HHSC]

Facility

$55.80

Service Code	NDC 00023079815
Hospital Charge Code	2500603
Hospital Revenue Code	250
Min. Negotiated Rate	$47.43
Max. Negotiated Rate	$54.13
Rate for Payer: Cash Price	$36.27
Rate for Payer: Health Management Network Commercial	$47.43
Rate for Payer: Kaiser Permanente Commercial	$50.22
Rate for Payer: MDX Hawaii PPO	$54.13

carboxymethylcellulos 0.5% ophth 15 mL [HHSC]

Facility

$55.80

Service Code	NDC 50268006815
Hospital Charge Code	2500603
Hospital Revenue Code	250
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$54.13
Rate for Payer: AlohaCare Medicaid	$27.90
Rate for Payer: AlohaCare Medicare	$27.90
Rate for Payer: Cash Price	$36.27
Rate for Payer: Devoted Health Medicare	$30.69
Rate for Payer: Hawaii Medical Service Association Medicare	$27.90
Rate for Payer: Hawaii Western Management Group Commercial	$53.01
Rate for Payer: Health Management Network Commercial	$47.43
Rate for Payer: Humana Medicare	$27.90
Rate for Payer: Kaiser Permanente Commercial	$50.22
Rate for Payer: Kaiser Permanente Medicaid	$28.46
Rate for Payer: Kaiser Permanente Medicare	$27.90
Rate for Payer: MDX Hawaii PPO	$54.13
Rate for Payer: Ohana Health Plan Medicaid	$27.90
Rate for Payer: Ohana Health Plan Medicare	$27.90
Rate for Payer: UnitedHealthcare Medicaid	$33.48
Rate for Payer: UnitedHealthcare Medicare	$27.90
Rate for Payer: University Health Alliance Commercial	$40.67

carboxymethylcellulos 0.5% ophth 15 mL [HHSC]

Facility

$55.80

Service Code	NDC 00023079815
Hospital Charge Code	2500603
Hospital Revenue Code	250
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$54.13
Rate for Payer: AlohaCare Medicaid	$27.90
Rate for Payer: AlohaCare Medicare	$27.90
Rate for Payer: Cash Price	$36.27
Rate for Payer: Devoted Health Medicare	$30.69
Rate for Payer: Hawaii Medical Service Association Medicare	$27.90
Rate for Payer: Hawaii Western Management Group Commercial	$53.01
Rate for Payer: Health Management Network Commercial	$47.43
Rate for Payer: Humana Medicare	$27.90
Rate for Payer: Kaiser Permanente Commercial	$50.22
Rate for Payer: Kaiser Permanente Medicaid	$28.46
Rate for Payer: Kaiser Permanente Medicare	$27.90
Rate for Payer: MDX Hawaii PPO	$54.13
Rate for Payer: Ohana Health Plan Medicaid	$27.90
Rate for Payer: Ohana Health Plan Medicare	$27.90
Rate for Payer: UnitedHealthcare Medicaid	$33.48
Rate for Payer: UnitedHealthcare Medicare	$27.90
Rate for Payer: University Health Alliance Commercial	$40.67

CARDIAC ARREST, UNEXPLAINED WITH CC

Facility

$44,678.27

Service Code	MSDRG 297
Min. Negotiated Rate	$44,678.27
Max. Negotiated Rate	$44,678.27
Rate for Payer: Hawaii Medical Service Association Commercial	$44,678.27

CARDIAC ARREST, UNEXPLAINED WITH MCC

Facility

$44,678.27

Service Code	MSDRG 296
Min. Negotiated Rate	$44,678.27
Max. Negotiated Rate	$44,678.27
Rate for Payer: Hawaii Medical Service Association Commercial	$44,678.27

CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC

Facility

$44,678.27

Service Code	MSDRG 298
Min. Negotiated Rate	$44,678.27
Max. Negotiated Rate	$44,678.27
Rate for Payer: Hawaii Medical Service Association Commercial	$44,678.27

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC

Facility

$19,814.87

Service Code	MSDRG 309
Min. Negotiated Rate	$19,814.87
Max. Negotiated Rate	$19,814.87
Rate for Payer: Hawaii Medical Service Association Commercial	$19,814.87

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC

Facility

$21,118.48

Service Code	MSDRG 308
Min. Negotiated Rate	$21,118.48
Max. Negotiated Rate	$21,118.48
Rate for Payer: Hawaii Medical Service Association Commercial	$21,118.48

CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC

Facility

$15,192.98

Service Code	MSDRG 310
Min. Negotiated Rate	$15,192.98
Max. Negotiated Rate	$15,192.98
Rate for Payer: Hawaii Medical Service Association Commercial	$15,192.98

Know your out-of-pocket cost for care.

All Charges