Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ciprofloxacin 500 mg tablet [HHSC]

Facility

$17.67

Service Code	NDC 68084007001
Hospital Charge Code	2500179
Hospital Revenue Code	250
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$17.14
Rate for Payer: AlohaCare Medicaid	$8.84
Rate for Payer: AlohaCare Medicare	$8.84
Rate for Payer: Cash Price	$11.49
Rate for Payer: Devoted Health Medicare	$9.72
Rate for Payer: Hawaii Medical Service Association Medicare	$8.84
Rate for Payer: Hawaii Western Management Group Commercial	$16.79
Rate for Payer: Health Management Network Commercial	$15.02
Rate for Payer: Humana Medicare	$8.84
Rate for Payer: Kaiser Permanente Commercial	$15.90
Rate for Payer: Kaiser Permanente Medicaid	$9.01
Rate for Payer: Kaiser Permanente Medicare	$8.84
Rate for Payer: MDX Hawaii PPO	$17.14
Rate for Payer: Ohana Health Plan Medicaid	$8.84
Rate for Payer: Ohana Health Plan Medicare	$8.84
Rate for Payer: UnitedHealthcare Medicaid	$10.60
Rate for Payer: UnitedHealthcare Medicare	$8.84
Rate for Payer: University Health Alliance Commercial	$12.88

ciprofloxacin 500 mg tablet [HHSC]

Facility

$17.67

Service Code	NDC 68084007001
Hospital Charge Code	2500179
Hospital Revenue Code	250
Min. Negotiated Rate	$15.02
Max. Negotiated Rate	$17.14
Rate for Payer: Cash Price	$11.49
Rate for Payer: Health Management Network Commercial	$15.02
Rate for Payer: Kaiser Permanente Commercial	$15.90
Rate for Payer: MDX Hawaii PPO	$17.14

ciprofloxacin 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904724361
Hospital Charge Code	2500179
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

ciprofloxacin 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904637861
Hospital Charge Code	2500179
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

ciprofloxacin 500 mg tablet [HHSC]

Facility

$31.06

Service Code	NDC 65862007701
Hospital Charge Code	2500179
Hospital Revenue Code	250
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$30.13
Rate for Payer: Cash Price	$20.19
Rate for Payer: Health Management Network Commercial	$26.40
Rate for Payer: Kaiser Permanente Commercial	$27.95
Rate for Payer: MDX Hawaii PPO	$30.13

ciprofloxacin 500 mg tablet [HHSC]

Facility

$31.06

Service Code	NDC 65862007701
Hospital Charge Code	2500179
Hospital Revenue Code	250
Min. Negotiated Rate	$15.53
Max. Negotiated Rate	$30.13
Rate for Payer: AlohaCare Medicaid	$15.53
Rate for Payer: AlohaCare Medicare	$15.53
Rate for Payer: Cash Price	$20.19
Rate for Payer: Devoted Health Medicare	$17.08
Rate for Payer: Hawaii Medical Service Association Medicare	$15.53
Rate for Payer: Hawaii Western Management Group Commercial	$29.51
Rate for Payer: Health Management Network Commercial	$26.40
Rate for Payer: Humana Medicare	$15.53
Rate for Payer: Kaiser Permanente Commercial	$27.95
Rate for Payer: Kaiser Permanente Medicaid	$15.84
Rate for Payer: Kaiser Permanente Medicare	$15.53
Rate for Payer: MDX Hawaii PPO	$30.13
Rate for Payer: Ohana Health Plan Medicaid	$15.53
Rate for Payer: Ohana Health Plan Medicare	$15.53
Rate for Payer: UnitedHealthcare Medicaid	$18.64
Rate for Payer: UnitedHealthcare Medicare	$15.53
Rate for Payer: University Health Alliance Commercial	$22.64

ciprofloxacin 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904724361
Hospital Charge Code	2500179
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

ciprofloxacin 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904708361
Hospital Charge Code	2500179
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

ciprofloxacin 500 mg tablet [HHSC]

Facility

$28.87

Service Code	NDC 55111012701
Hospital Charge Code	2500179
Hospital Revenue Code	250
Min. Negotiated Rate	$14.44
Max. Negotiated Rate	$28.00
Rate for Payer: AlohaCare Medicaid	$14.44
Rate for Payer: AlohaCare Medicare	$14.44
Rate for Payer: Cash Price	$18.77
Rate for Payer: Devoted Health Medicare	$15.88
Rate for Payer: Hawaii Medical Service Association Medicare	$14.44
Rate for Payer: Hawaii Western Management Group Commercial	$27.43
Rate for Payer: Health Management Network Commercial	$24.54
Rate for Payer: Humana Medicare	$14.44
Rate for Payer: Kaiser Permanente Commercial	$25.98
Rate for Payer: Kaiser Permanente Medicaid	$14.72
Rate for Payer: Kaiser Permanente Medicare	$14.44
Rate for Payer: MDX Hawaii PPO	$28.00
Rate for Payer: Ohana Health Plan Medicaid	$14.44
Rate for Payer: Ohana Health Plan Medicare	$14.44
Rate for Payer: UnitedHealthcare Medicaid	$17.32
Rate for Payer: UnitedHealthcare Medicare	$14.44
Rate for Payer: University Health Alliance Commercial	$21.04

ciprofloxacin 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904708361
Hospital Charge Code	2500179
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

ciprofloxacin 500 mg tablet [HHSC]

Facility

$28.87

Service Code	NDC 55111012701
Hospital Charge Code	2500179
Hospital Revenue Code	250
Min. Negotiated Rate	$24.54
Max. Negotiated Rate	$28.00
Rate for Payer: Cash Price	$18.77
Rate for Payer: Health Management Network Commercial	$24.54
Rate for Payer: Kaiser Permanente Commercial	$25.98
Rate for Payer: MDX Hawaii PPO	$28.00

ciprofloxacin 500 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904637861
Hospital Charge Code	2500179
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

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC

Facility

$34,130.88

Service Code	MSDRG 286
Min. Negotiated Rate	$34,130.88
Max. Negotiated Rate	$34,130.88
Rate for Payer: Hawaii Medical Service Association Commercial	$34,130.88

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$30,054.14

Service Code	MSDRG 287
Min. Negotiated Rate	$30,054.14
Max. Negotiated Rate	$30,054.14
Rate for Payer: Hawaii Medical Service Association Commercial	$30,054.14

Circumcision

Facility

$3,886.26

Service Code	HCPCS 54150
Hospital Charge Code	12486399
Hospital Revenue Code	723
Min. Negotiated Rate	$3,303.32
Max. Negotiated Rate	$3,769.67
Rate for Payer: Cash Price	$2,526.07
Rate for Payer: Health Management Network Commercial	$3,303.32
Rate for Payer: Kaiser Permanente Commercial	$3,497.63
Rate for Payer: MDX Hawaii PPO	$3,769.67

Circumcision

Professional

Both

$374.00

Service Code	HCPCS 54150
Hospital Charge Code	12486399
Hospital Revenue Code	960
Min. Negotiated Rate	$82.76
Max. Negotiated Rate	$317.90
Rate for Payer: AlohaCare Medicaid	$94.88
Rate for Payer: AlohaCare Medicare	$82.76
Rate for Payer: Cash Price	$243.10
Rate for Payer: Cash Price	$243.10
Rate for Payer: Devoted Health Medicare	$91.04
Rate for Payer: Hawaii Medical Service Association ABD	$94.88
Rate for Payer: Hawaii Medical Service Association Commercial	$149.31
Rate for Payer: Hawaii Medical Service Association Medicare	$82.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$94.88
Rate for Payer: Hawaii Western Management Group Commercial	$165.10
Rate for Payer: Health Management Network Commercial	$317.90
Rate for Payer: Kaiser Permanente Commercial	$99.31
Rate for Payer: Kaiser Permanente Medicaid	$99.31
Rate for Payer: Kaiser Permanente Medicare	$99.31
Rate for Payer: Ohana Health Plan Medicaid	$94.88
Rate for Payer: Ohana Health Plan Medicare	$82.76
Rate for Payer: UnitedHealthcare Medicaid	$94.88
Rate for Payer: UnitedHealthcare Medicare	$82.76
Rate for Payer: University Health Alliance Commercial	$126.42

Circumcision

Facility

$400.00

Service Code	HCPCS 54150
Hospital Charge Code	12480401
Hospital Revenue Code	761
Min. Negotiated Rate	$340.00
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: MDX Hawaii PPO	$388.00

Circumcision

Facility

$3,886.26

Service Code	HCPCS 54150
Hospital Charge Code	12486399
Hospital Revenue Code	723
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,943.13
Rate for Payer: AlohaCare Medicare	$1,943.13
Rate for Payer: Cash Price	$2,526.07
Rate for Payer: Cash Price	$2,526.07
Rate for Payer: Cash Price	$2,526.07
Rate for Payer: Devoted Health Medicare	$2,137.44
Rate for Payer: Hawaii Medical Service Association Commercial	$2,669.57
Rate for Payer: Hawaii Medical Service Association Medicare	$1,943.13
Rate for Payer: Hawaii Western Management Group Commercial	$3,691.95
Rate for Payer: Health Management Network Commercial	$3,303.32
Rate for Payer: Humana Medicare	$1,943.13
Rate for Payer: Kaiser Permanente Commercial	$3,497.63
Rate for Payer: Kaiser Permanente Medicaid	$1,981.99
Rate for Payer: Kaiser Permanente Medicare	$1,943.13
Rate for Payer: MDX Hawaii PPO	$3,769.67
Rate for Payer: Ohana Health Plan Medicaid	$1,943.13
Rate for Payer: Ohana Health Plan Medicare	$1,943.13
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,943.13
Rate for Payer: University Health Alliance Commercial	$4,035.20

Circumcision

Facility

$400.00

Service Code	HCPCS 54150
Hospital Charge Code	12480401
Hospital Revenue Code	761
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$200.00
Rate for Payer: AlohaCare Medicare	$200.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Devoted Health Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,669.57
Rate for Payer: Hawaii Medical Service Association Medicare	$200.00
Rate for Payer: Hawaii Western Management Group Commercial	$380.00
Rate for Payer: Health Management Network Commercial	$340.00
Rate for Payer: Humana Medicare	$200.00
Rate for Payer: Kaiser Permanente Commercial	$360.00
Rate for Payer: Kaiser Permanente Medicaid	$204.00
Rate for Payer: Kaiser Permanente Medicare	$200.00
Rate for Payer: MDX Hawaii PPO	$388.00
Rate for Payer: Ohana Health Plan Medicaid	$200.00
Rate for Payer: Ohana Health Plan Medicare	$200.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$200.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC

Facility

$41,336.29

Service Code	MSDRG 433
Min. Negotiated Rate	$41,336.29
Max. Negotiated Rate	$41,336.29
Rate for Payer: Hawaii Medical Service Association Commercial	$41,336.29

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC

Facility

$41,336.29

Service Code	MSDRG 432
Min. Negotiated Rate	$41,336.29
Max. Negotiated Rate	$41,336.29
Rate for Payer: Hawaii Medical Service Association Commercial	$41,336.29

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$41,336.29

Service Code	MSDRG 434
Min. Negotiated Rate	$41,336.29
Max. Negotiated Rate	$41,336.29
Rate for Payer: Hawaii Medical Service Association Commercial	$41,336.29

Citrate, Urine 24 Hour FSI

Facility

$316.00

Service Code	HCPCS 82507
Hospital Charge Code	8228854
Hospital Revenue Code	301
Min. Negotiated Rate	$268.60
Max. Negotiated Rate	$306.52
Rate for Payer: Cash Price	$205.40
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: MDX Hawaii PPO	$306.52

Citrate, Urine 24 Hour FSI

Facility

$316.00

Service Code	HCPCS 82507
Hospital Charge Code	8228854
Hospital Revenue Code	301
Min. Negotiated Rate	$27.80
Max. Negotiated Rate	$306.52
Rate for Payer: AlohaCare Medicaid	$158.00
Rate for Payer: AlohaCare Medicare	$158.00
Rate for Payer: Cash Price	$205.40
Rate for Payer: Cash Price	$205.40
Rate for Payer: Devoted Health Medicare	$173.80
Rate for Payer: Hawaii Medical Service Association ABD	$38.43
Rate for Payer: Hawaii Medical Service Association Commercial	$34.75
Rate for Payer: Hawaii Medical Service Association Medicare	$158.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.35
Rate for Payer: Hawaii Western Management Group Commercial	$27.80
Rate for Payer: Health Management Network Commercial	$268.60
Rate for Payer: Humana Medicare	$158.00
Rate for Payer: Kaiser Permanente Commercial	$284.40
Rate for Payer: Kaiser Permanente Medicaid	$161.16
Rate for Payer: Kaiser Permanente Medicare	$158.00
Rate for Payer: MDX Hawaii PPO	$306.52
Rate for Payer: Ohana Health Plan Medicaid	$158.00
Rate for Payer: Ohana Health Plan Medicare	$158.00
Rate for Payer: UnitedHealthcare Medicaid	$38.43
Rate for Payer: UnitedHealthcare Medicare	$158.00
Rate for Payer: University Health Alliance Commercial	$71.87

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	$8.46
Max. Negotiated Rate	$16.41
Rate for Payer: AlohaCare Medicaid	$8.46
Rate for Payer: AlohaCare Medicare	$8.46
Rate for Payer: Cash Price	$11.00
Rate for Payer: Devoted Health Medicare	$9.31
Rate for Payer: Hawaii Medical Service Association Medicare	$8.46
Rate for Payer: Hawaii Western Management Group Commercial	$16.07
Rate for Payer: Health Management Network Commercial	$14.38
Rate for Payer: Humana Medicare	$8.46
Rate for Payer: Kaiser Permanente Commercial	$15.23
Rate for Payer: Kaiser Permanente Medicaid	$8.63
Rate for Payer: Kaiser Permanente Medicare	$8.46
Rate for Payer: MDX Hawaii PPO	$16.41
Rate for Payer: Ohana Health Plan Medicaid	$8.46
Rate for Payer: Ohana Health Plan Medicare	$8.46
Rate for Payer: UnitedHealthcare Medicare	$8.46
Rate for Payer: University Health Alliance Commercial	$9.48

Know your out-of-pocket cost for care.

All Charges