Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

divalproex ER 250 mg tablet [HHSC]

Facility

$3.45

Service Code	NDC 50268025915
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.35
Rate for Payer: AlohaCare Medicaid	$1.73
Rate for Payer: AlohaCare Medicare	$1.73
Rate for Payer: Cash Price	$2.24
Rate for Payer: Devoted Health Medicare	$1.90
Rate for Payer: Hawaii Medical Service Association Medicare	$1.73
Rate for Payer: Hawaii Western Management Group Commercial	$3.28
Rate for Payer: Health Management Network Commercial	$2.93
Rate for Payer: Humana Medicare	$1.73
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: Kaiser Permanente Medicaid	$1.76
Rate for Payer: Kaiser Permanente Medicare	$1.73
Rate for Payer: MDX Hawaii PPO	$3.35
Rate for Payer: Ohana Health Plan Medicaid	$1.73
Rate for Payer: Ohana Health Plan Medicare	$1.73
Rate for Payer: UnitedHealthcare Medicaid	$2.07
Rate for Payer: UnitedHealthcare Medicare	$1.73
Rate for Payer: University Health Alliance Commercial	$2.51

divalproex ER 250 mg tablet [HHSC]

Facility

$13.61

Service Code	NDC 68084031001
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$13.20
Rate for Payer: Cash Price	$8.85
Rate for Payer: Health Management Network Commercial	$11.57
Rate for Payer: Kaiser Permanente Commercial	$12.25
Rate for Payer: MDX Hawaii PPO	$13.20

divalproex ER 250 mg tablet [HHSC]

Facility

$13.61

Service Code	NDC 68084031001
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$13.20
Rate for Payer: AlohaCare Medicaid	$6.80
Rate for Payer: AlohaCare Medicare	$6.80
Rate for Payer: Cash Price	$8.85
Rate for Payer: Devoted Health Medicare	$7.49
Rate for Payer: Hawaii Medical Service Association Medicare	$6.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.93
Rate for Payer: Health Management Network Commercial	$11.57
Rate for Payer: Humana Medicare	$6.80
Rate for Payer: Kaiser Permanente Commercial	$12.25
Rate for Payer: Kaiser Permanente Medicaid	$6.94
Rate for Payer: Kaiser Permanente Medicare	$6.80
Rate for Payer: MDX Hawaii PPO	$13.20
Rate for Payer: Ohana Health Plan Medicaid	$6.80
Rate for Payer: Ohana Health Plan Medicare	$6.80
Rate for Payer: UnitedHealthcare Medicaid	$8.17
Rate for Payer: UnitedHealthcare Medicare	$6.80
Rate for Payer: University Health Alliance Commercial	$9.92

divalproex ER 250 mg tablet [HHSC]

Facility

$3.45

Service Code	NDC 50268025915
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$3.35
Rate for Payer: Cash Price	$2.24
Rate for Payer: Health Management Network Commercial	$2.93
Rate for Payer: Kaiser Permanente Commercial	$3.10
Rate for Payer: MDX Hawaii PPO	$3.35

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 65862059401
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$13.24
Rate for Payer: Cash Price	$8.87
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: MDX Hawaii PPO	$13.24

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 65862059401
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$13.24
Rate for Payer: AlohaCare Medicaid	$6.83
Rate for Payer: AlohaCare Medicare	$6.83
Rate for Payer: Cash Price	$8.87
Rate for Payer: Devoted Health Medicare	$7.51
Rate for Payer: Hawaii Medical Service Association Medicare	$6.83
Rate for Payer: Hawaii Western Management Group Commercial	$12.97
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Humana Medicare	$6.83
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: Kaiser Permanente Medicaid	$6.96
Rate for Payer: Kaiser Permanente Medicare	$6.83
Rate for Payer: MDX Hawaii PPO	$13.24
Rate for Payer: Ohana Health Plan Medicaid	$6.83
Rate for Payer: Ohana Health Plan Medicare	$6.83
Rate for Payer: UnitedHealthcare Medicaid	$8.19
Rate for Payer: UnitedHealthcare Medicare	$6.83
Rate for Payer: University Health Alliance Commercial	$9.95

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 68001010500
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$13.24
Rate for Payer: AlohaCare Medicaid	$6.83
Rate for Payer: AlohaCare Medicare	$6.83
Rate for Payer: Cash Price	$8.87
Rate for Payer: Devoted Health Medicare	$7.51
Rate for Payer: Hawaii Medical Service Association Medicare	$6.83
Rate for Payer: Hawaii Western Management Group Commercial	$12.97
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Humana Medicare	$6.83
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: Kaiser Permanente Medicaid	$6.96
Rate for Payer: Kaiser Permanente Medicare	$6.83
Rate for Payer: MDX Hawaii PPO	$13.24
Rate for Payer: Ohana Health Plan Medicaid	$6.83
Rate for Payer: Ohana Health Plan Medicare	$6.83
Rate for Payer: UnitedHealthcare Medicaid	$8.19
Rate for Payer: UnitedHealthcare Medicare	$6.83
Rate for Payer: University Health Alliance Commercial	$9.95

divalproex ER 250 mg tablet [HHSC]

Facility

$13.65

Service Code	NDC 68001010500
Hospital Charge Code	2500263
Hospital Revenue Code	250
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$13.24
Rate for Payer: Cash Price	$8.87
Rate for Payer: Health Management Network Commercial	$11.60
Rate for Payer: Kaiser Permanente Commercial	$12.29
Rate for Payer: MDX Hawaii PPO	$13.24

divalproex ER 500 mg tablet [HHSC]

Facility

$16.82

Service Code	NDC 68084041502
Hospital Charge Code	2500264
Hospital Revenue Code	250
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$16.32
Rate for Payer: Cash Price	$10.93
Rate for Payer: Health Management Network Commercial	$14.30
Rate for Payer: Kaiser Permanente Commercial	$15.14
Rate for Payer: MDX Hawaii PPO	$16.32

divalproex ER 500 mg tablet [HHSC]

Facility

$16.82

Service Code	NDC 68084041502
Hospital Charge Code	2500264
Hospital Revenue Code	250
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$16.32
Rate for Payer: AlohaCare Medicaid	$8.41
Rate for Payer: AlohaCare Medicare	$8.41
Rate for Payer: Cash Price	$10.93
Rate for Payer: Devoted Health Medicare	$9.25
Rate for Payer: Hawaii Medical Service Association Medicare	$8.41
Rate for Payer: Hawaii Western Management Group Commercial	$15.98
Rate for Payer: Health Management Network Commercial	$14.30
Rate for Payer: Humana Medicare	$8.41
Rate for Payer: Kaiser Permanente Commercial	$15.14
Rate for Payer: Kaiser Permanente Medicaid	$8.58
Rate for Payer: Kaiser Permanente Medicare	$8.41
Rate for Payer: MDX Hawaii PPO	$16.32
Rate for Payer: Ohana Health Plan Medicaid	$8.41
Rate for Payer: Ohana Health Plan Medicare	$8.41
Rate for Payer: UnitedHealthcare Medicaid	$10.09
Rate for Payer: UnitedHealthcare Medicare	$8.41
Rate for Payer: University Health Alliance Commercial	$12.26

divalproex ER 500 mg tablet [HHSC]

Facility

$21.71

Service Code	NDC 68084041501
Hospital Charge Code	2500264
Hospital Revenue Code	250
Min. Negotiated Rate	$18.45
Max. Negotiated Rate	$21.06
Rate for Payer: Cash Price	$14.11
Rate for Payer: Health Management Network Commercial	$18.45
Rate for Payer: Kaiser Permanente Commercial	$19.54
Rate for Payer: MDX Hawaii PPO	$21.06

divalproex ER 500 mg tablet [HHSC]

Facility

$21.71

Service Code	NDC 68084041501
Hospital Charge Code	2500264
Hospital Revenue Code	250
Min. Negotiated Rate	$10.86
Max. Negotiated Rate	$21.06
Rate for Payer: AlohaCare Medicaid	$10.86
Rate for Payer: AlohaCare Medicare	$10.86
Rate for Payer: Cash Price	$14.11
Rate for Payer: Devoted Health Medicare	$11.94
Rate for Payer: Hawaii Medical Service Association Medicare	$10.86
Rate for Payer: Hawaii Western Management Group Commercial	$20.62
Rate for Payer: Health Management Network Commercial	$18.45
Rate for Payer: Humana Medicare	$10.86
Rate for Payer: Kaiser Permanente Commercial	$19.54
Rate for Payer: Kaiser Permanente Medicaid	$11.07
Rate for Payer: Kaiser Permanente Medicare	$10.86
Rate for Payer: MDX Hawaii PPO	$21.06
Rate for Payer: Ohana Health Plan Medicaid	$10.86
Rate for Payer: Ohana Health Plan Medicare	$10.86
Rate for Payer: UnitedHealthcare Medicaid	$13.03
Rate for Payer: UnitedHealthcare Medicare	$10.86
Rate for Payer: University Health Alliance Commercial	$15.82

DLCO ANY METHOD CHARGE

Facility

$455.00

Service Code	HCPCS 94729
Hospital Charge Code	8243388
Hospital Revenue Code	460
Min. Negotiated Rate	$31.25
Max. Negotiated Rate	$441.35
Rate for Payer: AlohaCare Medicaid	$227.50
Rate for Payer: AlohaCare Medicare	$227.50
Rate for Payer: Cash Price	$295.75
Rate for Payer: Cash Price	$295.75
Rate for Payer: Devoted Health Medicare	$250.25
Rate for Payer: Hawaii Medical Service Association ABD	$31.25
Rate for Payer: Hawaii Medical Service Association Medicare	$227.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$44.88
Rate for Payer: Hawaii Western Management Group Commercial	$432.25
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: Humana Medicare	$227.50
Rate for Payer: Kaiser Permanente Commercial	$409.50
Rate for Payer: Kaiser Permanente Medicaid	$232.05
Rate for Payer: Kaiser Permanente Medicare	$227.50
Rate for Payer: MDX Hawaii PPO	$441.35
Rate for Payer: Ohana Health Plan Medicaid	$227.50
Rate for Payer: Ohana Health Plan Medicare	$227.50
Rate for Payer: UnitedHealthcare Medicaid	$31.25
Rate for Payer: UnitedHealthcare Medicare	$227.50
Rate for Payer: University Health Alliance Commercial	$254.80

DLCO ANY METHOD CHARGE

Facility

$455.00

Service Code	HCPCS 94729
Hospital Charge Code	8243388
Hospital Revenue Code	460
Min. Negotiated Rate	$386.75
Max. Negotiated Rate	$441.35
Rate for Payer: Cash Price	$295.75
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: Kaiser Permanente Commercial	$409.50
Rate for Payer: MDX Hawaii PPO	$441.35

DLS5583A-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12516201
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583A-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12516201
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583B-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12561268
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583B-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12561268
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583C-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12564297
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583C-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12564297
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583D-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12564298
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583D-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12564298
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583E-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12562890
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

DLS5583E-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12562890
Hospital Revenue Code	306
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DLS5583F-MIC Panel Susceptibility

Facility

$107.00

Service Code	HCPCS 87186
Hospital Charge Code	12562891
Hospital Revenue Code	306
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association ABD	$11.94
Rate for Payer: Hawaii Medical Service Association Commercial	$10.81
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.54
Rate for Payer: Hawaii Western Management Group Commercial	$8.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicaid	$11.94
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$22.35

Know your out-of-pocket cost for care.

All Charges