Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

DRILL, LARGE HUDSON,CANNULATED, 5.5MM

Facility

$650.00

Hospital Charge Code	12985801
Hospital Revenue Code	272
Min. Negotiated Rate	$552.50
Max. Negotiated Rate	$630.50
Rate for Payer: Cash Price	$422.50
Rate for Payer: Health Management Network Commercial	$552.50
Rate for Payer: Kaiser Permanente Commercial	$585.00
Rate for Payer: MDX Hawaii PPO	$630.50

DRILL, LARGE HUDSON,CANNULATED, 5.5MM

Facility

$650.00

Hospital Charge Code	12985801
Hospital Revenue Code	272
Min. Negotiated Rate	$325.00
Max. Negotiated Rate	$630.50
Rate for Payer: AlohaCare Medicaid	$325.00
Rate for Payer: AlohaCare Medicare	$325.00
Rate for Payer: Cash Price	$422.50
Rate for Payer: Devoted Health Medicare	$357.50
Rate for Payer: Hawaii Medical Service Association Medicare	$325.00
Rate for Payer: Hawaii Western Management Group Commercial	$617.50
Rate for Payer: Health Management Network Commercial	$552.50
Rate for Payer: Humana Medicare	$325.00
Rate for Payer: Kaiser Permanente Commercial	$585.00
Rate for Payer: Kaiser Permanente Medicaid	$331.50
Rate for Payer: Kaiser Permanente Medicare	$325.00
Rate for Payer: MDX Hawaii PPO	$630.50
Rate for Payer: Ohana Health Plan Medicaid	$325.00
Rate for Payer: Ohana Health Plan Medicare	$325.00
Rate for Payer: UnitedHealthcare Medicare	$325.00
Rate for Payer: University Health Alliance Commercial	$473.79

droperidol 5 mg/2 mL vial [HHSC]

Facility

$60.00

Service Code	HCPCS J1790
Hospital Charge Code	2501087
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$39.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: MDX Hawaii PPO	$58.20

droperidol 5 mg/2 mL vial [HHSC]

Facility

$60.00

Service Code	HCPCS J1790
Hospital Charge Code	2501087
Hospital Revenue Code	636
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$58.20
Rate for Payer: AlohaCare Medicaid	$30.00
Rate for Payer: AlohaCare Medicare	$30.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Devoted Health Medicare	$33.00
Rate for Payer: Hawaii Medical Service Association ABD	$5.36
Rate for Payer: Hawaii Medical Service Association Medicare	$30.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.36
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Humana Medicare	$30.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicare	$30.00
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: Ohana Health Plan Medicaid	$30.00
Rate for Payer: Ohana Health Plan Medicare	$30.00
Rate for Payer: UnitedHealthcare Medicaid	$36.00
Rate for Payer: UnitedHealthcare Medicare	$30.00
Rate for Payer: University Health Alliance Commercial	$43.73

Drug Detection Panel, Meconium, Qualitative FSI

Facility

$1,118.00

Service Code	HCPCS G0481
Hospital Charge Code	10654595
Hospital Revenue Code	300
Min. Negotiated Rate	$73.79
Max. Negotiated Rate	$1,084.46
Rate for Payer: AlohaCare Medicaid	$559.00
Rate for Payer: AlohaCare Medicare	$559.00
Rate for Payer: Cash Price	$726.70
Rate for Payer: Cash Price	$726.70
Rate for Payer: Devoted Health Medicare	$614.90
Rate for Payer: Hawaii Medical Service Association Commercial	$195.74
Rate for Payer: Hawaii Medical Service Association Medicare	$559.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,062.10
Rate for Payer: Health Management Network Commercial	$950.30
Rate for Payer: Humana Medicare	$559.00
Rate for Payer: Kaiser Permanente Commercial	$1,006.20
Rate for Payer: Kaiser Permanente Medicaid	$570.18
Rate for Payer: Kaiser Permanente Medicare	$559.00
Rate for Payer: MDX Hawaii PPO	$1,084.46
Rate for Payer: Ohana Health Plan Medicaid	$559.00
Rate for Payer: Ohana Health Plan Medicare	$559.00
Rate for Payer: UnitedHealthcare Medicaid	$73.79
Rate for Payer: UnitedHealthcare Medicare	$559.00
Rate for Payer: University Health Alliance Commercial	$626.08

Drug Detection Panel, Meconium, Qualitative FSI

Facility

$1,118.00

Service Code	HCPCS G0481
Hospital Charge Code	10654595
Hospital Revenue Code	300
Min. Negotiated Rate	$950.30
Max. Negotiated Rate	$1,084.46
Rate for Payer: Cash Price	$726.70
Rate for Payer: Health Management Network Commercial	$950.30
Rate for Payer: Kaiser Permanente Commercial	$1,006.20
Rate for Payer: MDX Hawaii PPO	$1,084.46

Drug Detection Panel, Meconium, Qualitative FSI 3000326

Facility

$408.00

Service Code	HCPCS 80326
Hospital Charge Code	10845693
Hospital Revenue Code	300
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

Drug Detection Panel, Meconium, Qualitative FSI 3000326

Facility

$408.00

Service Code	HCPCS 80326
Hospital Charge Code	10845693
Hospital Revenue Code	300
Min. Negotiated Rate	$21.48
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$204.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$224.40
Rate for Payer: Hawaii Medical Service Association ABD	$21.48
Rate for Payer: Hawaii Medical Service Association Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.55
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$204.00
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$204.00
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$204.00
Rate for Payer: Ohana Health Plan Medicare	$204.00
Rate for Payer: UnitedHealthcare Medicare	$204.00
Rate for Payer: University Health Alliance Commercial	$228.48

Drug Detection Panel, Meconium, Qualitative FSI 3000347

Facility

$408.00

Service Code	HCPCS 80347
Hospital Charge Code	10654743
Hospital Revenue Code	300
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

Drug Detection Panel, Meconium, Qualitative FSI 3000347

Facility

$408.00

Service Code	HCPCS 80347
Hospital Charge Code	10654743
Hospital Revenue Code	300
Min. Negotiated Rate	$25.56
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$204.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$224.40
Rate for Payer: Hawaii Medical Service Association ABD	$25.56
Rate for Payer: Hawaii Medical Service Association Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.84
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$204.00
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$204.00
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$204.00
Rate for Payer: Ohana Health Plan Medicare	$204.00
Rate for Payer: UnitedHealthcare Medicare	$204.00
Rate for Payer: University Health Alliance Commercial	$228.48

Drug Detection Panel, Meconium, Qualitative FSI 3000356

Facility

$408.00

Service Code	HCPCS 80355
Hospital Charge Code	10655265
Hospital Revenue Code	300
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

Drug Detection Panel, Meconium, Qualitative FSI 3000356

Facility

$408.00

Service Code	HCPCS 80355
Hospital Charge Code	10655265
Hospital Revenue Code	300
Min. Negotiated Rate	$18.31
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$204.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$224.40
Rate for Payer: Hawaii Medical Service Association ABD	$18.31
Rate for Payer: Hawaii Medical Service Association Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.23
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$204.00
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$204.00
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$204.00
Rate for Payer: Ohana Health Plan Medicare	$204.00
Rate for Payer: UnitedHealthcare Medicare	$204.00
Rate for Payer: University Health Alliance Commercial	$228.48

Drug Detection Panel, Meconium, Qualitative FSI 3000364

Facility

$408.00

Service Code	HCPCS 80364
Hospital Charge Code	10654747
Hospital Revenue Code	300
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

Drug Detection Panel, Meconium, Qualitative FSI 3000364

Facility

$408.00

Service Code	HCPCS 80364
Hospital Charge Code	10654747
Hospital Revenue Code	300
Min. Negotiated Rate	$26.89
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$204.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$224.40
Rate for Payer: Hawaii Medical Service Association ABD	$26.89
Rate for Payer: Hawaii Medical Service Association Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.23
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$204.00
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$204.00
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$204.00
Rate for Payer: Ohana Health Plan Medicare	$204.00
Rate for Payer: UnitedHealthcare Medicare	$204.00
Rate for Payer: University Health Alliance Commercial	$228.48

Drug Detection Panel, Meconium, Qualitative FSI 3000481

Facility

$1,118.00

Service Code	HCPCS G0481
Hospital Charge Code	10655268
Hospital Revenue Code	300
Min. Negotiated Rate	$73.79
Max. Negotiated Rate	$1,084.46
Rate for Payer: AlohaCare Medicaid	$559.00
Rate for Payer: AlohaCare Medicare	$559.00
Rate for Payer: Cash Price	$726.70
Rate for Payer: Cash Price	$726.70
Rate for Payer: Devoted Health Medicare	$614.90
Rate for Payer: Hawaii Medical Service Association Commercial	$195.74
Rate for Payer: Hawaii Medical Service Association Medicare	$559.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,062.10
Rate for Payer: Health Management Network Commercial	$950.30
Rate for Payer: Humana Medicare	$559.00
Rate for Payer: Kaiser Permanente Commercial	$1,006.20
Rate for Payer: Kaiser Permanente Medicaid	$570.18
Rate for Payer: Kaiser Permanente Medicare	$559.00
Rate for Payer: MDX Hawaii PPO	$1,084.46
Rate for Payer: Ohana Health Plan Medicaid	$559.00
Rate for Payer: Ohana Health Plan Medicare	$559.00
Rate for Payer: UnitedHealthcare Medicaid	$73.79
Rate for Payer: UnitedHealthcare Medicare	$559.00
Rate for Payer: University Health Alliance Commercial	$626.08

Drug Detection Panel, Meconium, Qualitative FSI 3000481

Facility

$1,118.00

Service Code	HCPCS G0481
Hospital Charge Code	10655268
Hospital Revenue Code	300
Min. Negotiated Rate	$950.30
Max. Negotiated Rate	$1,084.46
Rate for Payer: Cash Price	$726.70
Rate for Payer: Health Management Network Commercial	$950.30
Rate for Payer: Kaiser Permanente Commercial	$1,006.20
Rate for Payer: MDX Hawaii PPO	$1,084.46

Drug Screening POC

Professional

Both

$88.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	1019796
Hospital Revenue Code	521
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$8.98
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Devoted Health Medicare	$13.86
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$14.95
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$15.12
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Ohana Health Plan Medicaid	$8.98
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$339.46

Drug Screening POC

Professional

Both

$88.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	8106687
Hospital Revenue Code	301
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$74.80
Rate for Payer: AlohaCare Medicaid	$8.98
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Devoted Health Medicare	$13.86
Rate for Payer: Hawaii Medical Service Association Medicare	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$14.95
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$15.12
Rate for Payer: Kaiser Permanente Medicaid	$15.12
Rate for Payer: Kaiser Permanente Medicare	$15.12
Rate for Payer: Ohana Health Plan Medicaid	$8.98
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$12.60

Drug Screen POC

Facility

$149.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	8041483
Hospital Revenue Code	301
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Drug Screen POC

Facility

$149.00

Service Code	HCPCS 80305 QW
Hospital Charge Code	8041483
Hospital Revenue Code	301
Min. Negotiated Rate	$8.98
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$19.03
Rate for Payer: Hawaii Medical Service Association Commercial	$15.75
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.11
Rate for Payer: Hawaii Western Management Group Commercial	$12.60
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$27.68

DTAP-IPV-HIB-HEPB VACCINE IM

Professional

Both

$241.00

Service Code	HCPCS 90697
Hospital Charge Code	11029903
Hospital Revenue Code	636
Min. Negotiated Rate	$204.85
Max. Negotiated Rate	$204.85
Rate for Payer: Cash Price	$156.65
Rate for Payer: Health Management Network Commercial	$204.85

DULoxetine 20 mg capsule [HHSC]

Facility

$43.72

Service Code	HCPCS J8499
Hospital Charge Code	2501062
Hospital Revenue Code	250
Min. Negotiated Rate	$37.16
Max. Negotiated Rate	$42.41
Rate for Payer: Cash Price	$28.42
Rate for Payer: Cash Price	$32.14
Rate for Payer: Health Management Network Commercial	$37.16
Rate for Payer: Health Management Network Commercial	$42.02
Rate for Payer: Kaiser Permanente Commercial	$39.35
Rate for Payer: Kaiser Permanente Commercial	$44.50
Rate for Payer: MDX Hawaii PPO	$47.96
Rate for Payer: MDX Hawaii PPO	$42.41

DULoxetine 20 mg capsule [HHSC]

Facility

$49.44

Service Code	HCPCS J8499
Hospital Charge Code	2501062
Hospital Revenue Code	636
Min. Negotiated Rate	$24.72
Max. Negotiated Rate	$47.96
Rate for Payer: AlohaCare Medicaid	$24.72
Rate for Payer: AlohaCare Medicaid	$21.86
Rate for Payer: AlohaCare Medicare	$21.86
Rate for Payer: AlohaCare Medicare	$24.72
Rate for Payer: Cash Price	$28.42
Rate for Payer: Cash Price	$32.14
Rate for Payer: Devoted Health Medicare	$24.05
Rate for Payer: Devoted Health Medicare	$27.19
Rate for Payer: Hawaii Medical Service Association Medicare	$24.72
Rate for Payer: Hawaii Medical Service Association Medicare	$21.86
Rate for Payer: Hawaii Western Management Group Commercial	$46.97
Rate for Payer: Hawaii Western Management Group Commercial	$41.53
Rate for Payer: Health Management Network Commercial	$37.16
Rate for Payer: Health Management Network Commercial	$42.02
Rate for Payer: Humana Medicare	$21.86
Rate for Payer: Humana Medicare	$24.72
Rate for Payer: Kaiser Permanente Commercial	$39.35
Rate for Payer: Kaiser Permanente Commercial	$44.50
Rate for Payer: Kaiser Permanente Medicaid	$22.30
Rate for Payer: Kaiser Permanente Medicaid	$25.21
Rate for Payer: Kaiser Permanente Medicare	$24.72
Rate for Payer: Kaiser Permanente Medicare	$21.86
Rate for Payer: MDX Hawaii PPO	$42.41
Rate for Payer: MDX Hawaii PPO	$47.96
Rate for Payer: Ohana Health Plan Medicaid	$24.72
Rate for Payer: Ohana Health Plan Medicaid	$21.86
Rate for Payer: Ohana Health Plan Medicare	$21.86
Rate for Payer: Ohana Health Plan Medicare	$24.72
Rate for Payer: UnitedHealthcare Medicaid	$29.66
Rate for Payer: UnitedHealthcare Medicaid	$26.23
Rate for Payer: UnitedHealthcare Medicare	$21.86
Rate for Payer: UnitedHealthcare Medicare	$24.72
Rate for Payer: University Health Alliance Commercial	$31.87
Rate for Payer: University Health Alliance Commercial	$36.04

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 60687073401
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.59
Max. Negotiated Rate	$45.76
Rate for Payer: AlohaCare Medicaid	$23.59
Rate for Payer: AlohaCare Medicare	$23.59
Rate for Payer: Cash Price	$30.67
Rate for Payer: Devoted Health Medicare	$25.95
Rate for Payer: Hawaii Medical Service Association Medicare	$23.59
Rate for Payer: Hawaii Western Management Group Commercial	$44.82
Rate for Payer: Health Management Network Commercial	$40.10
Rate for Payer: Humana Medicare	$23.59
Rate for Payer: Kaiser Permanente Commercial	$42.46
Rate for Payer: Kaiser Permanente Medicaid	$24.06
Rate for Payer: Kaiser Permanente Medicare	$23.59
Rate for Payer: MDX Hawaii PPO	$45.76
Rate for Payer: Ohana Health Plan Medicaid	$23.59
Rate for Payer: Ohana Health Plan Medicare	$23.59
Rate for Payer: UnitedHealthcare Medicaid	$28.31
Rate for Payer: UnitedHealthcare Medicare	$23.59
Rate for Payer: University Health Alliance Commercial	$34.39

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 68084068301
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.10
Max. Negotiated Rate	$45.76
Rate for Payer: Cash Price	$30.67
Rate for Payer: Health Management Network Commercial	$40.10
Rate for Payer: Kaiser Permanente Commercial	$42.46
Rate for Payer: MDX Hawaii PPO	$45.76

Know your out-of-pocket cost for care.

All Charges