Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

esmolol 100 mg/10mL vial [HHSC]

Facility

$52.54

Service Code	NDC 55150019410
Hospital Charge Code	2500312
Hospital Revenue Code	250
Min. Negotiated Rate	$44.66
Max. Negotiated Rate	$50.96
Rate for Payer: Cash Price	$34.15
Rate for Payer: Health Management Network Commercial	$44.66
Rate for Payer: Kaiser Permanente Commercial	$47.29
Rate for Payer: MDX Hawaii PPO	$50.96

esmolol-ns 2500 mg/250ml premix [HHSC]

Facility

$1,414.93

Service Code	NDC 10019005561
Hospital Charge Code	2500313
Hospital Revenue Code	250
Min. Negotiated Rate	$1,202.69
Max. Negotiated Rate	$1,372.48
Rate for Payer: Cash Price	$919.70
Rate for Payer: Health Management Network Commercial	$1,202.69
Rate for Payer: Kaiser Permanente Commercial	$1,273.44
Rate for Payer: MDX Hawaii PPO	$1,372.48

esmolol-ns 2500 mg/250ml premix [HHSC]

Facility

$1,414.93

Service Code	NDC 10019005561
Hospital Charge Code	2500313
Hospital Revenue Code	250
Min. Negotiated Rate	$707.47
Max. Negotiated Rate	$1,372.48
Rate for Payer: AlohaCare Medicaid	$707.47
Rate for Payer: AlohaCare Medicare	$707.47
Rate for Payer: Cash Price	$919.70
Rate for Payer: Devoted Health Medicare	$778.21
Rate for Payer: Hawaii Medical Service Association Medicare	$707.47
Rate for Payer: Hawaii Western Management Group Commercial	$1,344.18
Rate for Payer: Health Management Network Commercial	$1,202.69
Rate for Payer: Humana Medicare	$707.47
Rate for Payer: Kaiser Permanente Commercial	$1,273.44
Rate for Payer: Kaiser Permanente Medicaid	$721.61
Rate for Payer: Kaiser Permanente Medicare	$707.47
Rate for Payer: MDX Hawaii PPO	$1,372.48
Rate for Payer: Ohana Health Plan Medicaid	$707.47
Rate for Payer: Ohana Health Plan Medicare	$707.47
Rate for Payer: UnitedHealthcare Medicaid	$848.96
Rate for Payer: UnitedHealthcare Medicare	$707.47
Rate for Payer: University Health Alliance Commercial	$1,031.34

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$16,923.23

Service Code	MSDRG 391
Min. Negotiated Rate	$16,923.23
Max. Negotiated Rate	$16,923.23
Rate for Payer: Hawaii Medical Service Association Commercial	$16,923.23

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$14,553.03

Service Code	MSDRG 392
Min. Negotiated Rate	$14,553.03
Max. Negotiated Rate	$14,553.03
Rate for Payer: Hawaii Medical Service Association Commercial	$14,553.03

ESR (Westergren) FSI

Facility

$55.00

Service Code	HCPCS 85651
Hospital Charge Code	8117905
Hospital Revenue Code	305
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association ABD	$4.91
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.16
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicaid	$4.91
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$9.18

ESR (Westergren) FSI

Facility

$55.00

Service Code	HCPCS 85651
Hospital Charge Code	8117905
Hospital Revenue Code	305
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

Estradiol FSI

Facility

$318.00

Service Code	HCPCS 82670
Hospital Charge Code	8117906
Hospital Revenue Code	301
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$206.70
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: MDX Hawaii PPO	$308.46

Estradiol FSI

Facility

$318.00

Service Code	HCPCS 82670
Hospital Charge Code	8117906
Hospital Revenue Code	301
Min. Negotiated Rate	$27.94
Max. Negotiated Rate	$308.46
Rate for Payer: AlohaCare Medicaid	$159.00
Rate for Payer: AlohaCare Medicare	$159.00
Rate for Payer: Cash Price	$206.70
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$174.90
Rate for Payer: Hawaii Medical Service Association ABD	$38.62
Rate for Payer: Hawaii Medical Service Association Commercial	$34.92
Rate for Payer: Hawaii Medical Service Association Medicare	$159.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.55
Rate for Payer: Hawaii Western Management Group Commercial	$27.94
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Humana Medicare	$159.00
Rate for Payer: Kaiser Permanente Commercial	$286.20
Rate for Payer: Kaiser Permanente Medicaid	$162.18
Rate for Payer: Kaiser Permanente Medicare	$159.00
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: Ohana Health Plan Medicaid	$159.00
Rate for Payer: Ohana Health Plan Medicare	$159.00
Rate for Payer: UnitedHealthcare Medicaid	$38.62
Rate for Payer: UnitedHealthcare Medicare	$159.00
Rate for Payer: University Health Alliance Commercial	$72.22

ES TROCH NAIL, LT, 10MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984010
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984010
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984015
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984015
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 36CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984016
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 36CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984016
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 39CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984017
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 39CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984017
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984013
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984013
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984011
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 10MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984011
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 11MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984012
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 11MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984012
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 11MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984018
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, LT, 11MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12984018
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

Know your out-of-pocket cost for care.

All Charges