Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

doxepin 50 mg capsule [HHSC]

Facility

$6.55

Service Code	NDC 27241016901
Hospital Charge Code	2500275
Hospital Revenue Code	250
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$6.35
Rate for Payer: Cash Price	$4.26
Rate for Payer: Health Management Network Commercial	$5.57
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: MDX Hawaii PPO	$6.35

doxepin 50 mg capsule [HHSC]

Facility

$6.55

Service Code	NDC 00378425001
Hospital Charge Code	2500275
Hospital Revenue Code	250
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$6.35
Rate for Payer: Cash Price	$4.26
Rate for Payer: Health Management Network Commercial	$5.57
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: MDX Hawaii PPO	$6.35

doxepin 50 mg capsule [HHSC]

Facility

$6.55

Service Code	NDC 49884021901
Hospital Charge Code	2500275
Hospital Revenue Code	250
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$6.35
Rate for Payer: AlohaCare Medicaid	$3.27
Rate for Payer: AlohaCare Medicare	$3.27
Rate for Payer: Cash Price	$4.26
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Hawaii Medical Service Association Medicare	$3.27
Rate for Payer: Hawaii Western Management Group Commercial	$6.22
Rate for Payer: Health Management Network Commercial	$5.57
Rate for Payer: Humana Medicare	$3.27
Rate for Payer: Kaiser Permanente Commercial	$5.89
Rate for Payer: Kaiser Permanente Medicaid	$3.34
Rate for Payer: Kaiser Permanente Medicare	$3.27
Rate for Payer: MDX Hawaii PPO	$6.35
Rate for Payer: Ohana Health Plan Medicaid	$3.27
Rate for Payer: Ohana Health Plan Medicare	$3.27
Rate for Payer: UnitedHealthcare Medicaid	$3.93
Rate for Payer: UnitedHealthcare Medicare	$3.27
Rate for Payer: University Health Alliance Commercial	$4.77

doxycycline 100 mg tablet [HHSC]

Facility

$31.07

Service Code	NDC 62584069321
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$30.14
Rate for Payer: Cash Price	$20.20
Rate for Payer: Health Management Network Commercial	$26.41
Rate for Payer: Kaiser Permanente Commercial	$27.96
Rate for Payer: MDX Hawaii PPO	$30.14

doxycycline 100 mg tablet [HHSC]

Facility

$31.07

Service Code	NDC 62584069321
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$30.14
Rate for Payer: AlohaCare Medicaid	$15.54
Rate for Payer: AlohaCare Medicare	$15.54
Rate for Payer: Cash Price	$20.20
Rate for Payer: Devoted Health Medicare	$17.09
Rate for Payer: Hawaii Medical Service Association Medicare	$15.54
Rate for Payer: Hawaii Western Management Group Commercial	$29.52
Rate for Payer: Health Management Network Commercial	$26.41
Rate for Payer: Humana Medicare	$15.54
Rate for Payer: Kaiser Permanente Commercial	$27.96
Rate for Payer: Kaiser Permanente Medicaid	$15.85
Rate for Payer: Kaiser Permanente Medicare	$15.54
Rate for Payer: MDX Hawaii PPO	$30.14
Rate for Payer: Ohana Health Plan Medicaid	$15.54
Rate for Payer: Ohana Health Plan Medicare	$15.54
Rate for Payer: UnitedHealthcare Medicaid	$18.64
Rate for Payer: UnitedHealthcare Medicare	$15.54
Rate for Payer: University Health Alliance Commercial	$22.65

doxycycline 100 mg tablet [HHSC]

Facility

$29.72

Service Code	NDC 50268027915
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$14.86
Max. Negotiated Rate	$28.83
Rate for Payer: AlohaCare Medicaid	$14.86
Rate for Payer: AlohaCare Medicare	$14.86
Rate for Payer: Cash Price	$19.32
Rate for Payer: Devoted Health Medicare	$16.35
Rate for Payer: Hawaii Medical Service Association Medicare	$14.86
Rate for Payer: Hawaii Western Management Group Commercial	$28.23
Rate for Payer: Health Management Network Commercial	$25.26
Rate for Payer: Humana Medicare	$14.86
Rate for Payer: Kaiser Permanente Commercial	$26.75
Rate for Payer: Kaiser Permanente Medicaid	$15.16
Rate for Payer: Kaiser Permanente Medicare	$14.86
Rate for Payer: MDX Hawaii PPO	$28.83
Rate for Payer: Ohana Health Plan Medicaid	$14.86
Rate for Payer: Ohana Health Plan Medicare	$14.86
Rate for Payer: UnitedHealthcare Medicaid	$17.83
Rate for Payer: UnitedHealthcare Medicare	$14.86
Rate for Payer: University Health Alliance Commercial	$21.66

doxycycline 100 mg tablet [HHSC]

Facility

$39.62

Service Code	NDC 53489012002
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$38.43
Rate for Payer: Cash Price	$25.75
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: MDX Hawaii PPO	$38.43

doxycycline 100 mg tablet [HHSC]

Facility

$39.62

Service Code	NDC 72578000118
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$38.43
Rate for Payer: AlohaCare Medicaid	$19.81
Rate for Payer: AlohaCare Medicare	$19.81
Rate for Payer: Cash Price	$25.75
Rate for Payer: Devoted Health Medicare	$21.79
Rate for Payer: Hawaii Medical Service Association Medicare	$19.81
Rate for Payer: Hawaii Western Management Group Commercial	$37.64
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Humana Medicare	$19.81
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: Kaiser Permanente Medicaid	$20.21
Rate for Payer: Kaiser Permanente Medicare	$19.81
Rate for Payer: MDX Hawaii PPO	$38.43
Rate for Payer: Ohana Health Plan Medicaid	$19.81
Rate for Payer: Ohana Health Plan Medicare	$19.81
Rate for Payer: UnitedHealthcare Medicaid	$23.77
Rate for Payer: UnitedHealthcare Medicare	$19.81
Rate for Payer: University Health Alliance Commercial	$28.88

doxycycline 100 mg tablet [HHSC]

Facility

$39.62

Service Code	NDC 72578000118
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$38.43
Rate for Payer: Cash Price	$25.75
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: MDX Hawaii PPO	$38.43

doxycycline 100 mg tablet [HHSC]

Facility

$39.62

Service Code	NDC 53489012002
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$38.43
Rate for Payer: AlohaCare Medicaid	$19.81
Rate for Payer: AlohaCare Medicare	$19.81
Rate for Payer: Cash Price	$25.75
Rate for Payer: Devoted Health Medicare	$21.79
Rate for Payer: Hawaii Medical Service Association Medicare	$19.81
Rate for Payer: Hawaii Western Management Group Commercial	$37.64
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Humana Medicare	$19.81
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: Kaiser Permanente Medicaid	$20.21
Rate for Payer: Kaiser Permanente Medicare	$19.81
Rate for Payer: MDX Hawaii PPO	$38.43
Rate for Payer: Ohana Health Plan Medicaid	$19.81
Rate for Payer: Ohana Health Plan Medicare	$19.81
Rate for Payer: UnitedHealthcare Medicaid	$23.77
Rate for Payer: UnitedHealthcare Medicare	$19.81
Rate for Payer: University Health Alliance Commercial	$28.88

doxycycline 100 mg tablet [HHSC]

Facility

$39.62

Service Code	NDC 27808023401
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$38.43
Rate for Payer: Cash Price	$25.75
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: MDX Hawaii PPO	$38.43

doxycycline 100 mg tablet [HHSC]

Facility

$39.62

Service Code	NDC 27808023401
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$38.43
Rate for Payer: AlohaCare Medicaid	$19.81
Rate for Payer: AlohaCare Medicare	$19.81
Rate for Payer: Cash Price	$25.75
Rate for Payer: Devoted Health Medicare	$21.79
Rate for Payer: Hawaii Medical Service Association Medicare	$19.81
Rate for Payer: Hawaii Western Management Group Commercial	$37.64
Rate for Payer: Health Management Network Commercial	$33.68
Rate for Payer: Humana Medicare	$19.81
Rate for Payer: Kaiser Permanente Commercial	$35.66
Rate for Payer: Kaiser Permanente Medicaid	$20.21
Rate for Payer: Kaiser Permanente Medicare	$19.81
Rate for Payer: MDX Hawaii PPO	$38.43
Rate for Payer: Ohana Health Plan Medicaid	$19.81
Rate for Payer: Ohana Health Plan Medicare	$19.81
Rate for Payer: UnitedHealthcare Medicaid	$23.77
Rate for Payer: UnitedHealthcare Medicare	$19.81
Rate for Payer: University Health Alliance Commercial	$28.88

doxycycline 100 mg tablet [HHSC]

Facility

$29.72

Service Code	NDC 50268027915
Hospital Charge Code	2500277
Hospital Revenue Code	250
Min. Negotiated Rate	$25.26
Max. Negotiated Rate	$28.83
Rate for Payer: Cash Price	$19.32
Rate for Payer: Health Management Network Commercial	$25.26
Rate for Payer: Kaiser Permanente Commercial	$26.75
Rate for Payer: MDX Hawaii PPO	$28.83

DRAIN PENROSE 1/2 X 12

Facility

$11.00

Hospital Charge Code	8266556
Hospital Revenue Code	270
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$7.15
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: MDX Hawaii PPO	$10.67

DRAIN PENROSE 1/2 X 12

Facility

$11.00

Hospital Charge Code	8266556
Hospital Revenue Code	270
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$10.67
Rate for Payer: AlohaCare Medicaid	$5.50
Rate for Payer: AlohaCare Medicare	$5.50
Rate for Payer: Cash Price	$7.15
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5.50
Rate for Payer: Hawaii Western Management Group Commercial	$10.45
Rate for Payer: Health Management Network Commercial	$9.35
Rate for Payer: Humana Medicare	$5.50
Rate for Payer: Kaiser Permanente Commercial	$9.90
Rate for Payer: Kaiser Permanente Medicaid	$5.61
Rate for Payer: Kaiser Permanente Medicare	$5.50
Rate for Payer: MDX Hawaii PPO	$10.67
Rate for Payer: Ohana Health Plan Medicaid	$5.50
Rate for Payer: Ohana Health Plan Medicare	$5.50
Rate for Payer: UnitedHealthcare Medicare	$5.50
Rate for Payer: University Health Alliance Commercial	$8.02

DRAIN PENROSE 1/4 X 12

Facility

$8.00

Hospital Charge Code	8266336
Hospital Revenue Code	272
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$4.00
Rate for Payer: Cash Price	$5.20
Rate for Payer: Devoted Health Medicare	$4.40
Rate for Payer: Hawaii Medical Service Association Medicare	$4.00
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$4.00
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$4.00
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$4.00
Rate for Payer: UnitedHealthcare Medicare	$4.00
Rate for Payer: University Health Alliance Commercial	$5.83

DRAIN PENROSE 1/4 X 12

Facility

$8.00

Hospital Charge Code	8266336
Hospital Revenue Code	272
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$5.20
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

DRAIN PENROSE 1 X 12

Facility

$7.00

Hospital Charge Code	8266558
Hospital Revenue Code	270
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.55
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

DRAIN PENROSE 1 X 12

Facility

$7.00

Hospital Charge Code	8266558
Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$3.50
Rate for Payer: Cash Price	$4.55
Rate for Payer: Devoted Health Medicare	$3.85
Rate for Payer: Hawaii Medical Service Association Medicare	$3.50
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$3.50
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$3.50
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$3.50
Rate for Payer: Ohana Health Plan Medicare	$3.50
Rate for Payer: UnitedHealthcare Medicare	$3.50
Rate for Payer: University Health Alliance Commercial	$5.10

DRAIN PENROSE 5/8 X 12

Facility

$54.00

Hospital Charge Code	8266557
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$51.30
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$39.36

DRAIN PENROSE 5/8 X 12

Facility

$54.00

Hospital Charge Code	8266557
Hospital Revenue Code	270
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

DRESSING ALLDRESS 4X4

Facility

$9.00

Hospital Charge Code	8266892
Hospital Revenue Code	272
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: MDX Hawaii PPO	$8.73

DRESSING ALLDRESS 4X4

Facility

$9.00

Hospital Charge Code	8266892
Hospital Revenue Code	272
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$8.73
Rate for Payer: AlohaCare Medicaid	$4.50
Rate for Payer: AlohaCare Medicare	$4.50
Rate for Payer: Cash Price	$5.85
Rate for Payer: Devoted Health Medicare	$4.95
Rate for Payer: Hawaii Medical Service Association Medicare	$4.50
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Humana Medicare	$4.50
Rate for Payer: Kaiser Permanente Commercial	$8.10
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: Kaiser Permanente Medicare	$4.50
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: Ohana Health Plan Medicaid	$4.50
Rate for Payer: Ohana Health Plan Medicare	$4.50
Rate for Payer: UnitedHealthcare Medicare	$4.50
Rate for Payer: University Health Alliance Commercial	$6.56

DRESSING ALLDRESS 6X6

Facility

$10.00

Hospital Charge Code	8266891
Hospital Revenue Code	272
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.70
Rate for Payer: AlohaCare Medicaid	$5.00
Rate for Payer: AlohaCare Medicare	$5.00
Rate for Payer: Cash Price	$6.50
Rate for Payer: Devoted Health Medicare	$5.50
Rate for Payer: Hawaii Medical Service Association Medicare	$5.00
Rate for Payer: Hawaii Western Management Group Commercial	$9.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Humana Medicare	$5.00
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: Kaiser Permanente Medicaid	$5.10
Rate for Payer: Kaiser Permanente Medicare	$5.00
Rate for Payer: MDX Hawaii PPO	$9.70
Rate for Payer: Ohana Health Plan Medicaid	$5.00
Rate for Payer: Ohana Health Plan Medicare	$5.00
Rate for Payer: UnitedHealthcare Medicare	$5.00
Rate for Payer: University Health Alliance Commercial	$7.29

DRESSING ALLDRESS 6X6

Facility

$10.00

Hospital Charge Code	8266891
Hospital Revenue Code	272
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$6.50
Rate for Payer: Health Management Network Commercial	$8.50
Rate for Payer: Kaiser Permanente Commercial	$9.00
Rate for Payer: MDX Hawaii PPO	$9.70

Know your out-of-pocket cost for care.

All Charges