Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041405
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 68084068301
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

$47.87

Service Code	NDC 68001059505
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041404
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001059504
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041404
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001059505
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001041405
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$23.93
Max. Negotiated Rate	$46.43
Rate for Payer: AlohaCare Medicaid	$23.93
Rate for Payer: AlohaCare Medicare	$23.93
Rate for Payer: Cash Price	$31.12
Rate for Payer: Devoted Health Medicare	$26.33
Rate for Payer: Hawaii Medical Service Association Medicare	$23.93
Rate for Payer: Hawaii Western Management Group Commercial	$45.48
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Humana Medicare	$23.93
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: Kaiser Permanente Medicaid	$24.41
Rate for Payer: Kaiser Permanente Medicare	$23.93
Rate for Payer: MDX Hawaii PPO	$46.43
Rate for Payer: Ohana Health Plan Medicaid	$23.93
Rate for Payer: Ohana Health Plan Medicare	$23.93
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$23.93
Rate for Payer: University Health Alliance Commercial	$34.89

DULoxetine 30 mg capsule [HHSC]

Facility

$47.87

Service Code	NDC 68001059504
Hospital Charge Code	2500278
Hospital Revenue Code	250
Min. Negotiated Rate	$40.69
Max. Negotiated Rate	$46.43
Rate for Payer: Cash Price	$31.12
Rate for Payer: Health Management Network Commercial	$40.69
Rate for Payer: Kaiser Permanente Commercial	$43.08
Rate for Payer: MDX Hawaii PPO	$46.43

DULoxetine 30 mg capsule [HHSC]

Facility

$47.18

Service Code	NDC 60687073401
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

Duovisc Kit

Facility

$582.00

Hospital Charge Code	8527569
Hospital Revenue Code	272
Min. Negotiated Rate	$494.70
Max. Negotiated Rate	$564.54
Rate for Payer: Cash Price	$378.30
Rate for Payer: Health Management Network Commercial	$494.70
Rate for Payer: Kaiser Permanente Commercial	$523.80
Rate for Payer: MDX Hawaii PPO	$564.54

Duovisc Kit

Facility

$582.00

Hospital Charge Code	8527569
Hospital Revenue Code	272
Min. Negotiated Rate	$291.00
Max. Negotiated Rate	$564.54
Rate for Payer: AlohaCare Medicaid	$291.00
Rate for Payer: AlohaCare Medicare	$291.00
Rate for Payer: Cash Price	$378.30
Rate for Payer: Devoted Health Medicare	$320.10
Rate for Payer: Hawaii Medical Service Association Medicare	$291.00
Rate for Payer: Hawaii Western Management Group Commercial	$552.90
Rate for Payer: Health Management Network Commercial	$494.70
Rate for Payer: Humana Medicare	$291.00
Rate for Payer: Kaiser Permanente Commercial	$523.80
Rate for Payer: Kaiser Permanente Medicaid	$296.82
Rate for Payer: Kaiser Permanente Medicare	$291.00
Rate for Payer: MDX Hawaii PPO	$564.54
Rate for Payer: Ohana Health Plan Medicaid	$291.00
Rate for Payer: Ohana Health Plan Medicare	$291.00
Rate for Payer: UnitedHealthcare Medicare	$291.00
Rate for Payer: University Health Alliance Commercial	$424.22

DYSEQUILIBRIUM

Facility

$12,727.97

Service Code	MSDRG 149
Min. Negotiated Rate	$12,727.97
Max. Negotiated Rate	$12,727.97
Rate for Payer: Hawaii Medical Service Association Commercial	$12,727.97

E95705 EEG Tech - Unmonitored 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95705
Hospital Charge Code	12284971
Hospital Revenue Code	740
Min. Negotiated Rate	$1,683.85
Max. Negotiated Rate	$1,921.57
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: MDX Hawaii PPO	$1,921.57

E95705 EEG Tech - Unmonitored 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95705
Hospital Charge Code	12284971
Hospital Revenue Code	740
Min. Negotiated Rate	$233.55
Max. Negotiated Rate	$1,921.57
Rate for Payer: MDX Hawaii PPO	$1,921.57
Rate for Payer: AlohaCare Medicaid	$990.50
Rate for Payer: AlohaCare Medicare	$990.50
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Devoted Health Medicare	$1,089.55
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$990.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,881.95
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Humana Medicare	$990.50
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: Kaiser Permanente Medicaid	$1,010.31
Rate for Payer: Kaiser Permanente Medicare	$990.50
Rate for Payer: Ohana Health Plan Medicaid	$990.50
Rate for Payer: Ohana Health Plan Medicare	$990.50
Rate for Payer: UnitedHealthcare Medicaid	$233.55
Rate for Payer: UnitedHealthcare Medicare	$990.50
Rate for Payer: University Health Alliance Commercial	$1,109.36

E95706 EEG Tech - Intermittent Monitoring and Maintenance 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95706
Hospital Charge Code	12283600
Hospital Revenue Code	740
Min. Negotiated Rate	$1,683.85
Max. Negotiated Rate	$1,921.57
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: MDX Hawaii PPO	$1,921.57

E95706 EEG Tech - Intermittent Monitoring and Maintenance 2 to 12 hours

Facility

$1,981.00

Service Code	HCPCS 95706
Hospital Charge Code	12283600
Hospital Revenue Code	740
Min. Negotiated Rate	$233.55
Max. Negotiated Rate	$1,921.57
Rate for Payer: AlohaCare Medicaid	$990.50
Rate for Payer: AlohaCare Medicare	$990.50
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Cash Price	$1,287.65
Rate for Payer: Devoted Health Medicare	$1,089.55
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$990.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,881.95
Rate for Payer: Health Management Network Commercial	$1,683.85
Rate for Payer: Humana Medicare	$990.50
Rate for Payer: Kaiser Permanente Commercial	$1,782.90
Rate for Payer: Kaiser Permanente Medicaid	$1,010.31
Rate for Payer: Kaiser Permanente Medicare	$990.50
Rate for Payer: MDX Hawaii PPO	$1,921.57
Rate for Payer: Ohana Health Plan Medicaid	$990.50
Rate for Payer: Ohana Health Plan Medicare	$990.50
Rate for Payer: UnitedHealthcare Medicaid	$233.55
Rate for Payer: UnitedHealthcare Medicare	$990.50
Rate for Payer: University Health Alliance Commercial	$1,109.36

E95707 EEG Tech - Continuous Real Time Monitoring and Maintenance 2 to 12 hours

Facility

$1,346.00

Service Code	HCPCS 95707
Hospital Charge Code	12284973
Hospital Revenue Code	740
Min. Negotiated Rate	$233.55
Max. Negotiated Rate	$1,305.62
Rate for Payer: AlohaCare Medicaid	$673.00
Rate for Payer: AlohaCare Medicare	$673.00
Rate for Payer: Cash Price	$874.90
Rate for Payer: Cash Price	$874.90
Rate for Payer: Devoted Health Medicare	$740.30
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$673.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,278.70
Rate for Payer: Health Management Network Commercial	$1,144.10
Rate for Payer: Humana Medicare	$673.00
Rate for Payer: Kaiser Permanente Commercial	$1,211.40
Rate for Payer: Kaiser Permanente Medicaid	$686.46
Rate for Payer: Kaiser Permanente Medicare	$673.00
Rate for Payer: MDX Hawaii PPO	$1,305.62
Rate for Payer: Ohana Health Plan Medicaid	$673.00
Rate for Payer: Ohana Health Plan Medicare	$673.00
Rate for Payer: UnitedHealthcare Medicaid	$233.55
Rate for Payer: UnitedHealthcare Medicare	$673.00
Rate for Payer: University Health Alliance Commercial	$753.76

E95707 EEG Tech - Continuous Real Time Monitoring and Maintenance 2 to 12 hours

Facility

$1,346.00

Service Code	HCPCS 95707
Hospital Charge Code	12284973
Hospital Revenue Code	740
Min. Negotiated Rate	$1,144.10
Max. Negotiated Rate	$1,305.62
Rate for Payer: Cash Price	$874.90
Rate for Payer: Health Management Network Commercial	$1,144.10
Rate for Payer: Kaiser Permanente Commercial	$1,211.40
Rate for Payer: MDX Hawaii PPO	$1,305.62

E95708 EEG Tech - Unmonitored 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95708
Hospital Charge Code	12273626
Hospital Revenue Code	740
Min. Negotiated Rate	$397.95
Max. Negotiated Rate	$3,297.03
Rate for Payer: AlohaCare Medicaid	$1,699.50
Rate for Payer: AlohaCare Medicare	$1,699.50
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Devoted Health Medicare	$1,869.45
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,699.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,229.05
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Humana Medicare	$1,699.50
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: Kaiser Permanente Medicaid	$1,733.49
Rate for Payer: Kaiser Permanente Medicare	$1,699.50
Rate for Payer: MDX Hawaii PPO	$3,297.03
Rate for Payer: Ohana Health Plan Medicaid	$1,699.50
Rate for Payer: Ohana Health Plan Medicare	$1,699.50
Rate for Payer: UnitedHealthcare Medicaid	$397.95
Rate for Payer: UnitedHealthcare Medicare	$1,699.50
Rate for Payer: University Health Alliance Commercial	$1,903.44

E95708 EEG Tech - Unmonitored 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95708
Hospital Charge Code	12273626
Hospital Revenue Code	740
Min. Negotiated Rate	$2,889.15
Max. Negotiated Rate	$3,297.03
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: MDX Hawaii PPO	$3,297.03

E95709 EEG Tech - Intermittent Monitoring and Maintenance 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95709
Hospital Charge Code	12284972
Hospital Revenue Code	740
Min. Negotiated Rate	$2,889.15
Max. Negotiated Rate	$3,297.03
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: MDX Hawaii PPO	$3,297.03

E95709 EEG Tech - Intermittent Monitoring and Maintenance 12 to 26 hours each increment

Facility

$3,399.00

Service Code	HCPCS 95709
Hospital Charge Code	12284972
Hospital Revenue Code	740
Min. Negotiated Rate	$397.95
Max. Negotiated Rate	$3,297.03
Rate for Payer: AlohaCare Medicaid	$1,699.50
Rate for Payer: AlohaCare Medicare	$1,699.50
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Cash Price	$2,209.35
Rate for Payer: Devoted Health Medicare	$1,869.45
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,699.50
Rate for Payer: Hawaii Western Management Group Commercial	$3,229.05
Rate for Payer: Health Management Network Commercial	$2,889.15
Rate for Payer: Humana Medicare	$1,699.50
Rate for Payer: Kaiser Permanente Commercial	$3,059.10
Rate for Payer: Kaiser Permanente Medicaid	$1,733.49
Rate for Payer: Kaiser Permanente Medicare	$1,699.50
Rate for Payer: MDX Hawaii PPO	$3,297.03
Rate for Payer: Ohana Health Plan Medicaid	$1,699.50
Rate for Payer: Ohana Health Plan Medicare	$1,699.50
Rate for Payer: UnitedHealthcare Medicaid	$397.95
Rate for Payer: UnitedHealthcare Medicare	$1,699.50
Rate for Payer: University Health Alliance Commercial	$1,903.44

E95710 EEG Tech - Continuous Real Time Monitoring and Maintenance 12 to 26 hours each increment

Facility

$2,581.00

Service Code	HCPCS 95710
Hospital Charge Code	12273627
Hospital Revenue Code	740
Min. Negotiated Rate	$397.95
Max. Negotiated Rate	$2,503.57
Rate for Payer: AlohaCare Medicaid	$1,290.50
Rate for Payer: AlohaCare Medicare	$1,290.50
Rate for Payer: Cash Price	$1,677.65
Rate for Payer: Cash Price	$1,677.65
Rate for Payer: Devoted Health Medicare	$1,419.55
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,290.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,451.95
Rate for Payer: Health Management Network Commercial	$2,193.85
Rate for Payer: Humana Medicare	$1,290.50
Rate for Payer: Kaiser Permanente Commercial	$2,322.90
Rate for Payer: Kaiser Permanente Medicaid	$1,316.31
Rate for Payer: Kaiser Permanente Medicare	$1,290.50
Rate for Payer: MDX Hawaii PPO	$2,503.57
Rate for Payer: Ohana Health Plan Medicaid	$1,290.50
Rate for Payer: Ohana Health Plan Medicare	$1,290.50
Rate for Payer: UnitedHealthcare Medicaid	$397.95
Rate for Payer: UnitedHealthcare Medicare	$1,290.50
Rate for Payer: University Health Alliance Commercial	$1,445.36

E95710 EEG Tech - Continuous Real Time Monitoring and Maintenance 12 to 26 hours each increment

Facility

$2,581.00

Service Code	HCPCS 95710
Hospital Charge Code	12273627
Hospital Revenue Code	740
Min. Negotiated Rate	$2,193.85
Max. Negotiated Rate	$2,503.57
Rate for Payer: Cash Price	$1,677.65
Rate for Payer: Health Management Network Commercial	$2,193.85
Rate for Payer: Kaiser Permanente Commercial	$2,322.90
Rate for Payer: MDX Hawaii PPO	$2,503.57

Know your out-of-pocket cost for care.

All Charges