Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

digoxin 125 mcg tablet [HHSC]

Facility

$8.11

Service Code	NDC 60687085801
Hospital Charge Code	2500247
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$7.87
Rate for Payer: AlohaCare Medicaid	$4.05
Rate for Payer: AlohaCare Medicare	$4.05
Rate for Payer: Cash Price	$5.27
Rate for Payer: Devoted Health Medicare	$4.46
Rate for Payer: Hawaii Medical Service Association Medicare	$4.05
Rate for Payer: Hawaii Western Management Group Commercial	$7.70
Rate for Payer: Health Management Network Commercial	$6.89
Rate for Payer: Humana Medicare	$4.05
Rate for Payer: Kaiser Permanente Commercial	$7.30
Rate for Payer: Kaiser Permanente Medicaid	$4.14
Rate for Payer: Kaiser Permanente Medicare	$4.05
Rate for Payer: MDX Hawaii PPO	$7.87
Rate for Payer: Ohana Health Plan Medicaid	$4.05
Rate for Payer: Ohana Health Plan Medicare	$4.05
Rate for Payer: UnitedHealthcare Medicaid	$4.87
Rate for Payer: UnitedHealthcare Medicare	$4.05
Rate for Payer: University Health Alliance Commercial	$5.91

digoxin 125 mcg tablet [HHSC]

Facility

$12.79

Service Code	NDC 69238199101
Hospital Charge Code	2500247
Hospital Revenue Code	250
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$12.41
Rate for Payer: AlohaCare Medicaid	$6.39
Rate for Payer: AlohaCare Medicare	$6.39
Rate for Payer: Cash Price	$8.31
Rate for Payer: Devoted Health Medicare	$7.03
Rate for Payer: Hawaii Medical Service Association Medicare	$6.39
Rate for Payer: Hawaii Western Management Group Commercial	$12.15
Rate for Payer: Health Management Network Commercial	$10.87
Rate for Payer: Humana Medicare	$6.39
Rate for Payer: Kaiser Permanente Commercial	$11.51
Rate for Payer: Kaiser Permanente Medicaid	$6.52
Rate for Payer: Kaiser Permanente Medicare	$6.39
Rate for Payer: MDX Hawaii PPO	$12.41
Rate for Payer: Ohana Health Plan Medicaid	$6.39
Rate for Payer: Ohana Health Plan Medicare	$6.39
Rate for Payer: UnitedHealthcare Medicaid	$7.67
Rate for Payer: UnitedHealthcare Medicare	$6.39
Rate for Payer: University Health Alliance Commercial	$9.32

digoxin 125 mcg tablet [HHSC]

Facility

$12.79

Service Code	NDC 00143124001
Hospital Charge Code	2500247
Hospital Revenue Code	250
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$12.41
Rate for Payer: AlohaCare Medicaid	$6.39
Rate for Payer: AlohaCare Medicare	$6.39
Rate for Payer: Cash Price	$8.31
Rate for Payer: Devoted Health Medicare	$7.03
Rate for Payer: Hawaii Medical Service Association Medicare	$6.39
Rate for Payer: Hawaii Western Management Group Commercial	$12.15
Rate for Payer: Health Management Network Commercial	$10.87
Rate for Payer: Humana Medicare	$6.39
Rate for Payer: Kaiser Permanente Commercial	$11.51
Rate for Payer: Kaiser Permanente Medicaid	$6.52
Rate for Payer: Kaiser Permanente Medicare	$6.39
Rate for Payer: MDX Hawaii PPO	$12.41
Rate for Payer: Ohana Health Plan Medicaid	$6.39
Rate for Payer: Ohana Health Plan Medicare	$6.39
Rate for Payer: UnitedHealthcare Medicaid	$7.67
Rate for Payer: UnitedHealthcare Medicare	$6.39
Rate for Payer: University Health Alliance Commercial	$9.32

digoxin 125 mcg tablet [HHSC]

Facility

$8.11

Service Code	NDC 60687085801
Hospital Charge Code	2500247
Hospital Revenue Code	250
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$7.87
Rate for Payer: Cash Price	$5.27
Rate for Payer: Health Management Network Commercial	$6.89
Rate for Payer: Kaiser Permanente Commercial	$7.30
Rate for Payer: MDX Hawaii PPO	$7.87

digoxin 125 mcg tablet [HHSC]

Facility

$14.23

Service Code	NDC 68084036601
Hospital Charge Code	2500247
Hospital Revenue Code	250
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$13.80
Rate for Payer: AlohaCare Medicaid	$7.12
Rate for Payer: AlohaCare Medicare	$7.12
Rate for Payer: Cash Price	$9.25
Rate for Payer: Devoted Health Medicare	$7.83
Rate for Payer: Hawaii Medical Service Association Medicare	$7.12
Rate for Payer: Hawaii Western Management Group Commercial	$13.52
Rate for Payer: Health Management Network Commercial	$12.10
Rate for Payer: Humana Medicare	$7.12
Rate for Payer: Kaiser Permanente Commercial	$12.81
Rate for Payer: Kaiser Permanente Medicaid	$7.26
Rate for Payer: Kaiser Permanente Medicare	$7.12
Rate for Payer: MDX Hawaii PPO	$13.80
Rate for Payer: Ohana Health Plan Medicaid	$7.12
Rate for Payer: Ohana Health Plan Medicare	$7.12
Rate for Payer: UnitedHealthcare Medicaid	$8.54
Rate for Payer: UnitedHealthcare Medicare	$7.12
Rate for Payer: University Health Alliance Commercial	$10.37

digoxin 125 mcg tablet [HHSC]

Facility

$12.79

Service Code	NDC 69238199101
Hospital Charge Code	2500247
Hospital Revenue Code	250
Min. Negotiated Rate	$10.87
Max. Negotiated Rate	$12.41
Rate for Payer: Cash Price	$8.31
Rate for Payer: Health Management Network Commercial	$10.87
Rate for Payer: Kaiser Permanente Commercial	$11.51
Rate for Payer: MDX Hawaii PPO	$12.41

digoxin 500 mcg/2 mL ampule [HHSC]

Facility

$41.82

Service Code	HCPCS J1160
Hospital Charge Code	2500249
Hospital Revenue Code	250
Min. Negotiated Rate	$35.55
Max. Negotiated Rate	$40.57
Rate for Payer: Cash Price	$27.18
Rate for Payer: Health Management Network Commercial	$35.55
Rate for Payer: Kaiser Permanente Commercial	$37.64
Rate for Payer: MDX Hawaii PPO	$40.57

digoxin 500 mcg/2 mL ampule [HHSC]

Facility

$41.82

Service Code	HCPCS J1160
Hospital Charge Code	2500249
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$40.57
Rate for Payer: AlohaCare Medicaid	$20.91
Rate for Payer: AlohaCare Medicare	$20.91
Rate for Payer: Cash Price	$27.18
Rate for Payer: Cash Price	$27.18
Rate for Payer: Devoted Health Medicare	$23.00
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Medicare	$20.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$39.73
Rate for Payer: Health Management Network Commercial	$35.55
Rate for Payer: Humana Medicare	$20.91
Rate for Payer: Kaiser Permanente Commercial	$37.64
Rate for Payer: Kaiser Permanente Medicaid	$21.33
Rate for Payer: Kaiser Permanente Medicare	$20.91
Rate for Payer: MDX Hawaii PPO	$40.57
Rate for Payer: Ohana Health Plan Medicaid	$20.91
Rate for Payer: Ohana Health Plan Medicare	$20.91
Rate for Payer: UnitedHealthcare Medicaid	$25.09
Rate for Payer: UnitedHealthcare Medicare	$20.91
Rate for Payer: University Health Alliance Commercial	$30.48

Digoxin Level FSI

Facility

$153.00

Service Code	HCPCS 80162
Hospital Charge Code	8128121
Hospital Revenue Code	301
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$99.45
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

Digoxin Level FSI

Facility

$153.00

Service Code	HCPCS 80162
Hospital Charge Code	8128121
Hospital Revenue Code	301
Min. Negotiated Rate	$13.28
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$76.50
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cash Price	$99.45
Rate for Payer: Devoted Health Medicare	$84.15
Rate for Payer: Hawaii Medical Service Association ABD	$18.35
Rate for Payer: Hawaii Medical Service Association Commercial	$16.60
Rate for Payer: Hawaii Medical Service Association Medicare	$76.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.27
Rate for Payer: Hawaii Western Management Group Commercial	$13.28
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$76.50
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$76.50
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$76.50
Rate for Payer: Ohana Health Plan Medicare	$76.50
Rate for Payer: UnitedHealthcare Medicaid	$18.35
Rate for Payer: UnitedHealthcare Medicare	$76.50
Rate for Payer: University Health Alliance Commercial	$34.32

Dihydrotestosterone FSI

Facility

$324.00

Service Code	HCPCS 82642
Hospital Charge Code	12384290
Hospital Revenue Code	301
Min. Negotiated Rate	$19.52
Max. Negotiated Rate	$314.28
Rate for Payer: AlohaCare Medicaid	$162.00
Rate for Payer: AlohaCare Medicare	$162.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Devoted Health Medicare	$178.20
Rate for Payer: Hawaii Medical Service Association ABD	$24.54
Rate for Payer: Hawaii Medical Service Association Commercial	$36.60
Rate for Payer: Hawaii Medical Service Association Medicare	$162.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.44
Rate for Payer: Hawaii Western Management Group Commercial	$29.28
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Humana Medicare	$162.00
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: Kaiser Permanente Medicaid	$165.24
Rate for Payer: Kaiser Permanente Medicare	$162.00
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: Ohana Health Plan Medicaid	$162.00
Rate for Payer: Ohana Health Plan Medicare	$162.00
Rate for Payer: UnitedHealthcare Medicaid	$19.52
Rate for Payer: UnitedHealthcare Medicare	$162.00
Rate for Payer: University Health Alliance Commercial	$181.44

Dihydrotestosterone FSI

Facility

$324.00

Service Code	HCPCS 82642
Hospital Charge Code	12384290
Hospital Revenue Code	301
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$210.60
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$291.60
Rate for Payer: MDX Hawaii PPO	$314.28

DILATOR EZDILATE BALLOON DILATOR FW 11-12-13

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552527
Hospital Revenue Code	272
Min. Negotiated Rate	$768.40
Max. Negotiated Rate	$876.88
Rate for Payer: Cash Price	$587.60
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: MDX Hawaii PPO	$876.88

DILATOR EZDILATE BALLOON DILATOR FW 11-12-13

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552527
Hospital Revenue Code	272
Min. Negotiated Rate	$452.00
Max. Negotiated Rate	$876.88
Rate for Payer: AlohaCare Medicaid	$452.00
Rate for Payer: AlohaCare Medicare	$452.00
Rate for Payer: Cash Price	$587.60
Rate for Payer: Devoted Health Medicare	$497.20
Rate for Payer: Hawaii Medical Service Association Medicare	$452.00
Rate for Payer: Hawaii Western Management Group Commercial	$858.80
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Humana Medicare	$452.00
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: Kaiser Permanente Medicaid	$461.04
Rate for Payer: Kaiser Permanente Medicare	$452.00
Rate for Payer: MDX Hawaii PPO	$876.88
Rate for Payer: Ohana Health Plan Medicaid	$452.00
Rate for Payer: Ohana Health Plan Medicare	$452.00
Rate for Payer: UnitedHealthcare Medicare	$452.00
Rate for Payer: University Health Alliance Commercial	$658.93

DILATOR EZDILATE BALLOON DILATOR FW 13.5-14.5

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552526
Hospital Revenue Code	272
Min. Negotiated Rate	$452.00
Max. Negotiated Rate	$876.88
Rate for Payer: AlohaCare Medicaid	$452.00
Rate for Payer: AlohaCare Medicare	$452.00
Rate for Payer: Cash Price	$587.60
Rate for Payer: Devoted Health Medicare	$497.20
Rate for Payer: Hawaii Medical Service Association Medicare	$452.00
Rate for Payer: Hawaii Western Management Group Commercial	$858.80
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Humana Medicare	$452.00
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: Kaiser Permanente Medicaid	$461.04
Rate for Payer: Kaiser Permanente Medicare	$452.00
Rate for Payer: MDX Hawaii PPO	$876.88
Rate for Payer: Ohana Health Plan Medicaid	$452.00
Rate for Payer: Ohana Health Plan Medicare	$452.00
Rate for Payer: UnitedHealthcare Medicare	$452.00
Rate for Payer: University Health Alliance Commercial	$658.93

DILATOR EZDILATE BALLOON DILATOR FW 13.5-14.5

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552526
Hospital Revenue Code	272
Min. Negotiated Rate	$768.40
Max. Negotiated Rate	$876.88
Rate for Payer: Cash Price	$587.60
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: MDX Hawaii PPO	$876.88

DILATOR EZDILATE BALLOON DILATOR FW 16-17-18

Facility

$687.00

Service Code	HCPCS C1726
Hospital Charge Code	9552525
Hospital Revenue Code	272
Min. Negotiated Rate	$343.50
Max. Negotiated Rate	$666.39
Rate for Payer: AlohaCare Medicaid	$343.50
Rate for Payer: AlohaCare Medicare	$343.50
Rate for Payer: Cash Price	$446.55
Rate for Payer: Devoted Health Medicare	$377.85
Rate for Payer: Hawaii Medical Service Association Medicare	$343.50
Rate for Payer: Hawaii Western Management Group Commercial	$652.65
Rate for Payer: Health Management Network Commercial	$583.95
Rate for Payer: Humana Medicare	$343.50
Rate for Payer: Kaiser Permanente Commercial	$618.30
Rate for Payer: Kaiser Permanente Medicaid	$350.37
Rate for Payer: Kaiser Permanente Medicare	$343.50
Rate for Payer: MDX Hawaii PPO	$666.39
Rate for Payer: Ohana Health Plan Medicaid	$343.50
Rate for Payer: Ohana Health Plan Medicare	$343.50
Rate for Payer: UnitedHealthcare Medicare	$343.50
Rate for Payer: University Health Alliance Commercial	$500.75

DILATOR EZDILATE BALLOON DILATOR FW 16-17-18

Facility

$687.00

Service Code	HCPCS C1726
Hospital Charge Code	9552525
Hospital Revenue Code	272
Min. Negotiated Rate	$583.95
Max. Negotiated Rate	$666.39
Rate for Payer: Cash Price	$446.55
Rate for Payer: Health Management Network Commercial	$583.95
Rate for Payer: Kaiser Permanente Commercial	$618.30
Rate for Payer: MDX Hawaii PPO	$666.39

DILATOR EZDILATE BALLOON DILATOR FW 6-7-8

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552529
Hospital Revenue Code	272
Min. Negotiated Rate	$452.00
Max. Negotiated Rate	$876.88
Rate for Payer: AlohaCare Medicaid	$452.00
Rate for Payer: AlohaCare Medicare	$452.00
Rate for Payer: Cash Price	$587.60
Rate for Payer: Devoted Health Medicare	$497.20
Rate for Payer: Hawaii Medical Service Association Medicare	$452.00
Rate for Payer: Hawaii Western Management Group Commercial	$858.80
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Humana Medicare	$452.00
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: Kaiser Permanente Medicaid	$461.04
Rate for Payer: Kaiser Permanente Medicare	$452.00
Rate for Payer: MDX Hawaii PPO	$876.88
Rate for Payer: Ohana Health Plan Medicaid	$452.00
Rate for Payer: Ohana Health Plan Medicare	$452.00
Rate for Payer: UnitedHealthcare Medicare	$452.00
Rate for Payer: University Health Alliance Commercial	$658.93

DILATOR EZDILATE BALLOON DILATOR FW 6-7-8

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552529
Hospital Revenue Code	272
Min. Negotiated Rate	$768.40
Max. Negotiated Rate	$876.88
Rate for Payer: Cash Price	$587.60
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: MDX Hawaii PPO	$876.88

DILATOR EZDILATE BALLOON DILATOR FW 8.5-9.5-10

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552528
Hospital Revenue Code	272
Min. Negotiated Rate	$452.00
Max. Negotiated Rate	$876.88
Rate for Payer: AlohaCare Medicaid	$452.00
Rate for Payer: AlohaCare Medicare	$452.00
Rate for Payer: Cash Price	$587.60
Rate for Payer: Devoted Health Medicare	$497.20
Rate for Payer: Hawaii Medical Service Association Medicare	$452.00
Rate for Payer: Hawaii Western Management Group Commercial	$858.80
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Humana Medicare	$452.00
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: Kaiser Permanente Medicaid	$461.04
Rate for Payer: Kaiser Permanente Medicare	$452.00
Rate for Payer: MDX Hawaii PPO	$876.88
Rate for Payer: Ohana Health Plan Medicaid	$452.00
Rate for Payer: Ohana Health Plan Medicare	$452.00
Rate for Payer: UnitedHealthcare Medicare	$452.00
Rate for Payer: University Health Alliance Commercial	$658.93

DILATOR EZDILATE BALLOON DILATOR FW 8.5-9.5-10

Facility

$904.00

Service Code	HCPCS C1726
Hospital Charge Code	9552528
Hospital Revenue Code	272
Min. Negotiated Rate	$768.40
Max. Negotiated Rate	$876.88
Rate for Payer: Cash Price	$587.60
Rate for Payer: Health Management Network Commercial	$768.40
Rate for Payer: Kaiser Permanente Commercial	$813.60
Rate for Payer: MDX Hawaii PPO	$876.88

DILATOR EZDILATE BALLOON FW 18-19-20

Facility

$687.00

Service Code	HCPCS C1726
Hospital Charge Code	9552524
Hospital Revenue Code	272
Min. Negotiated Rate	$583.95
Max. Negotiated Rate	$666.39
Rate for Payer: Cash Price	$446.55
Rate for Payer: Health Management Network Commercial	$583.95
Rate for Payer: Kaiser Permanente Commercial	$618.30
Rate for Payer: MDX Hawaii PPO	$666.39

DILATOR EZDILATE BALLOON FW 18-19-20

Facility

$687.00

Service Code	HCPCS C1726
Hospital Charge Code	9552524
Hospital Revenue Code	272
Min. Negotiated Rate	$343.50
Max. Negotiated Rate	$666.39
Rate for Payer: AlohaCare Medicaid	$343.50
Rate for Payer: AlohaCare Medicare	$343.50
Rate for Payer: Cash Price	$446.55
Rate for Payer: Devoted Health Medicare	$377.85
Rate for Payer: Hawaii Medical Service Association Medicare	$343.50
Rate for Payer: Hawaii Western Management Group Commercial	$652.65
Rate for Payer: Health Management Network Commercial	$583.95
Rate for Payer: Humana Medicare	$343.50
Rate for Payer: Kaiser Permanente Commercial	$618.30
Rate for Payer: Kaiser Permanente Medicaid	$350.37
Rate for Payer: Kaiser Permanente Medicare	$343.50
Rate for Payer: MDX Hawaii PPO	$666.39
Rate for Payer: Ohana Health Plan Medicaid	$343.50
Rate for Payer: Ohana Health Plan Medicare	$343.50
Rate for Payer: UnitedHealthcare Medicare	$343.50
Rate for Payer: University Health Alliance Commercial	$500.75

diltiazem 125mg/25ml vial [HHSC]

Facility

$58.37

Service Code	HCPCS J1163
Hospital Charge Code	2500256
Hospital Revenue Code	250
Min. Negotiated Rate	$49.61
Max. Negotiated Rate	$56.62
Rate for Payer: Cash Price	$37.94
Rate for Payer: Cash Price	$32.01
Rate for Payer: Cash Price	$28.33
Rate for Payer: Health Management Network Commercial	$37.04
Rate for Payer: Health Management Network Commercial	$49.61
Rate for Payer: Health Management Network Commercial	$41.86
Rate for Payer: Kaiser Permanente Commercial	$44.33
Rate for Payer: Kaiser Permanente Commercial	$52.53
Rate for Payer: Kaiser Permanente Commercial	$39.22
Rate for Payer: MDX Hawaii PPO	$47.77
Rate for Payer: MDX Hawaii PPO	$42.27
Rate for Payer: MDX Hawaii PPO	$56.62

Know your out-of-pocket cost for care.

All Charges