Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.47

Service Code	NDC 68084089501
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$3.37
Rate for Payer: Cash Price	$2.26
Rate for Payer: Health Management Network Commercial	$2.95
Rate for Payer: Kaiser Permanente Commercial	$3.12
Rate for Payer: MDX Hawaii PPO	$3.37

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$4.42

Service Code	NDC 00406012362
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$4.29
Rate for Payer: AlohaCare Medicaid	$2.21
Rate for Payer: AlohaCare Medicare	$2.21
Rate for Payer: Cash Price	$2.87
Rate for Payer: Devoted Health Medicare	$2.43
Rate for Payer: Hawaii Medical Service Association Medicare	$2.21
Rate for Payer: Hawaii Western Management Group Commercial	$4.20
Rate for Payer: Health Management Network Commercial	$3.76
Rate for Payer: Humana Medicare	$2.21
Rate for Payer: Kaiser Permanente Commercial	$3.98
Rate for Payer: Kaiser Permanente Medicaid	$2.25
Rate for Payer: Kaiser Permanente Medicare	$2.21
Rate for Payer: MDX Hawaii PPO	$4.29
Rate for Payer: Ohana Health Plan Medicaid	$2.21
Rate for Payer: Ohana Health Plan Medicare	$2.21
Rate for Payer: UnitedHealthcare Medicaid	$2.65
Rate for Payer: UnitedHealthcare Medicare	$2.21
Rate for Payer: University Health Alliance Commercial	$3.22

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.84

Service Code	NDC 00406012301
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$3.72
Rate for Payer: AlohaCare Medicaid	$1.92
Rate for Payer: AlohaCare Medicare	$1.92
Rate for Payer: Cash Price	$2.50
Rate for Payer: Devoted Health Medicare	$2.11
Rate for Payer: Hawaii Medical Service Association Medicare	$1.92
Rate for Payer: Hawaii Western Management Group Commercial	$3.65
Rate for Payer: Health Management Network Commercial	$3.26
Rate for Payer: Humana Medicare	$1.92
Rate for Payer: Kaiser Permanente Commercial	$3.46
Rate for Payer: Kaiser Permanente Medicaid	$1.96
Rate for Payer: Kaiser Permanente Medicare	$1.92
Rate for Payer: MDX Hawaii PPO	$3.72
Rate for Payer: Ohana Health Plan Medicaid	$1.92
Rate for Payer: Ohana Health Plan Medicare	$1.92
Rate for Payer: UnitedHealthcare Medicaid	$2.30
Rate for Payer: UnitedHealthcare Medicare	$1.92
Rate for Payer: University Health Alliance Commercial	$2.80

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.84

Service Code	NDC 00406012301
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$3.26
Max. Negotiated Rate	$3.72
Rate for Payer: Cash Price	$2.50
Rate for Payer: Health Management Network Commercial	$3.26
Rate for Payer: Kaiser Permanente Commercial	$3.46
Rate for Payer: MDX Hawaii PPO	$3.72

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.82

Service Code	NDC 68084089509
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$3.71
Rate for Payer: AlohaCare Medicaid	$1.91
Rate for Payer: AlohaCare Medicare	$1.91
Rate for Payer: Cash Price	$2.48
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1.91
Rate for Payer: Hawaii Western Management Group Commercial	$3.63
Rate for Payer: Health Management Network Commercial	$3.25
Rate for Payer: Humana Medicare	$1.91
Rate for Payer: Kaiser Permanente Commercial	$3.44
Rate for Payer: Kaiser Permanente Medicaid	$1.95
Rate for Payer: Kaiser Permanente Medicare	$1.91
Rate for Payer: MDX Hawaii PPO	$3.71
Rate for Payer: Ohana Health Plan Medicaid	$1.91
Rate for Payer: Ohana Health Plan Medicare	$1.91
Rate for Payer: UnitedHealthcare Medicaid	$2.29
Rate for Payer: UnitedHealthcare Medicare	$1.91
Rate for Payer: University Health Alliance Commercial	$2.78

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.47

Service Code	NDC 68084089501
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$3.37
Rate for Payer: AlohaCare Medicaid	$1.74
Rate for Payer: AlohaCare Medicare	$1.74
Rate for Payer: Cash Price	$2.26
Rate for Payer: Devoted Health Medicare	$1.91
Rate for Payer: Hawaii Medical Service Association Medicare	$1.74
Rate for Payer: Hawaii Western Management Group Commercial	$3.30
Rate for Payer: Health Management Network Commercial	$2.95
Rate for Payer: Humana Medicare	$1.74
Rate for Payer: Kaiser Permanente Commercial	$3.12
Rate for Payer: Kaiser Permanente Medicaid	$1.77
Rate for Payer: Kaiser Permanente Medicare	$1.74
Rate for Payer: MDX Hawaii PPO	$3.37
Rate for Payer: Ohana Health Plan Medicaid	$1.74
Rate for Payer: Ohana Health Plan Medicare	$1.74
Rate for Payer: UnitedHealthcare Medicaid	$2.08
Rate for Payer: UnitedHealthcare Medicare	$1.74
Rate for Payer: University Health Alliance Commercial	$2.53

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904682461
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904682461
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$4.42

Service Code	NDC 00406012362
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$4.29
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Management Network Commercial	$3.76
Rate for Payer: Kaiser Permanente Commercial	$3.98
Rate for Payer: MDX Hawaii PPO	$4.29

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.82

Service Code	NDC 68084089509
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$3.71
Rate for Payer: Cash Price	$2.48
Rate for Payer: Health Management Network Commercial	$3.25
Rate for Payer: Kaiser Permanente Commercial	$3.44
Rate for Payer: MDX Hawaii PPO	$3.71

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.47

Service Code	NDC 60687039601
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$3.37
Rate for Payer: AlohaCare Medicaid	$1.74
Rate for Payer: AlohaCare Medicare	$1.74
Rate for Payer: Cash Price	$2.26
Rate for Payer: Devoted Health Medicare	$1.91
Rate for Payer: Hawaii Medical Service Association Medicare	$1.74
Rate for Payer: Hawaii Western Management Group Commercial	$3.30
Rate for Payer: Health Management Network Commercial	$2.95
Rate for Payer: Humana Medicare	$1.74
Rate for Payer: Kaiser Permanente Commercial	$3.12
Rate for Payer: Kaiser Permanente Medicaid	$1.77
Rate for Payer: Kaiser Permanente Medicare	$1.74
Rate for Payer: MDX Hawaii PPO	$3.37
Rate for Payer: Ohana Health Plan Medicaid	$1.74
Rate for Payer: Ohana Health Plan Medicare	$1.74
Rate for Payer: UnitedHealthcare Medicaid	$2.08
Rate for Payer: UnitedHealthcare Medicare	$1.74
Rate for Payer: University Health Alliance Commercial	$2.53

HYDROcodone-APAP 5-325 mg tablet [HHSC]

Facility

$3.47

Service Code	NDC 60687039601
Hospital Charge Code	2500011
Hospital Revenue Code	250
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$3.37
Rate for Payer: Cash Price	$2.26
Rate for Payer: Health Management Network Commercial	$2.95
Rate for Payer: Kaiser Permanente Commercial	$3.12
Rate for Payer: MDX Hawaii PPO	$3.37

hydrocortisone 1% cream topical 28.35gm [HHSC]

Facility

$28.54

Service Code	NDC 51672206902
Hospital Charge Code	2500395
Hospital Revenue Code	250
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$27.68
Rate for Payer: Cash Price	$18.55
Rate for Payer: Health Management Network Commercial	$24.26
Rate for Payer: Kaiser Permanente Commercial	$25.69
Rate for Payer: MDX Hawaii PPO	$27.68

hydrocortisone 1% cream topical 28.35gm [HHSC]

Facility

$22.18

Service Code	NDC 45802043803
Hospital Charge Code	2500395
Hospital Revenue Code	250
Min. Negotiated Rate	$11.09
Max. Negotiated Rate	$21.51
Rate for Payer: AlohaCare Medicaid	$11.09
Rate for Payer: AlohaCare Medicare	$11.09
Rate for Payer: Cash Price	$14.42
Rate for Payer: Devoted Health Medicare	$12.20
Rate for Payer: Hawaii Medical Service Association Medicare	$11.09
Rate for Payer: Hawaii Western Management Group Commercial	$21.07
Rate for Payer: Health Management Network Commercial	$18.85
Rate for Payer: Humana Medicare	$11.09
Rate for Payer: Kaiser Permanente Commercial	$19.96
Rate for Payer: Kaiser Permanente Medicaid	$11.31
Rate for Payer: Kaiser Permanente Medicare	$11.09
Rate for Payer: MDX Hawaii PPO	$21.51
Rate for Payer: Ohana Health Plan Medicaid	$11.09
Rate for Payer: Ohana Health Plan Medicare	$11.09
Rate for Payer: UnitedHealthcare Medicaid	$13.31
Rate for Payer: UnitedHealthcare Medicare	$11.09
Rate for Payer: University Health Alliance Commercial	$16.17

hydrocortisone 1% cream topical 28.35gm [HHSC]

Facility

$22.18

Service Code	NDC 45802043803
Hospital Charge Code	2500395
Hospital Revenue Code	250
Min. Negotiated Rate	$18.85
Max. Negotiated Rate	$21.51
Rate for Payer: Cash Price	$14.42
Rate for Payer: Health Management Network Commercial	$18.85
Rate for Payer: Kaiser Permanente Commercial	$19.96
Rate for Payer: MDX Hawaii PPO	$21.51

hydrocortisone 1% cream topical 28.35gm [HHSC]

Facility

$26.36

Service Code	NDC 00168015431
Hospital Charge Code	2500395
Hospital Revenue Code	250
Min. Negotiated Rate	$13.18
Max. Negotiated Rate	$25.57
Rate for Payer: AlohaCare Medicaid	$13.18
Rate for Payer: AlohaCare Medicare	$13.18
Rate for Payer: Cash Price	$17.13
Rate for Payer: Devoted Health Medicare	$14.50
Rate for Payer: Hawaii Medical Service Association Medicare	$13.18
Rate for Payer: Hawaii Western Management Group Commercial	$25.04
Rate for Payer: Health Management Network Commercial	$22.41
Rate for Payer: Humana Medicare	$13.18
Rate for Payer: Kaiser Permanente Commercial	$23.72
Rate for Payer: Kaiser Permanente Medicaid	$13.44
Rate for Payer: Kaiser Permanente Medicare	$13.18
Rate for Payer: MDX Hawaii PPO	$25.57
Rate for Payer: Ohana Health Plan Medicaid	$13.18
Rate for Payer: Ohana Health Plan Medicare	$13.18
Rate for Payer: UnitedHealthcare Medicaid	$15.82
Rate for Payer: UnitedHealthcare Medicare	$13.18
Rate for Payer: University Health Alliance Commercial	$19.21

hydrocortisone 1% cream topical 28.35gm [HHSC]

Facility

$26.36

Service Code	NDC 00168015431
Hospital Charge Code	2500395
Hospital Revenue Code	250
Min. Negotiated Rate	$22.41
Max. Negotiated Rate	$25.57
Rate for Payer: Cash Price	$17.13
Rate for Payer: Health Management Network Commercial	$22.41
Rate for Payer: Kaiser Permanente Commercial	$23.72
Rate for Payer: MDX Hawaii PPO	$25.57

hydrocortisone 1% cream topical 28.35gm [HHSC]

Facility

$28.54

Service Code	NDC 51672206902
Hospital Charge Code	2500395
Hospital Revenue Code	250
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$27.68
Rate for Payer: AlohaCare Medicaid	$14.27
Rate for Payer: AlohaCare Medicare	$14.27
Rate for Payer: Cash Price	$18.55
Rate for Payer: Devoted Health Medicare	$15.70
Rate for Payer: Hawaii Medical Service Association Medicare	$14.27
Rate for Payer: Hawaii Western Management Group Commercial	$27.11
Rate for Payer: Health Management Network Commercial	$24.26
Rate for Payer: Humana Medicare	$14.27
Rate for Payer: Kaiser Permanente Commercial	$25.69
Rate for Payer: Kaiser Permanente Medicaid	$14.56
Rate for Payer: Kaiser Permanente Medicare	$14.27
Rate for Payer: MDX Hawaii PPO	$27.68
Rate for Payer: Ohana Health Plan Medicaid	$14.27
Rate for Payer: Ohana Health Plan Medicare	$14.27
Rate for Payer: UnitedHealthcare Medicaid	$17.12
Rate for Payer: UnitedHealthcare Medicare	$14.27
Rate for Payer: University Health Alliance Commercial	$20.80

hydrocortisone 2.5% cream rectal [HHSC]

Facility

$389.83

Service Code	NDC 62559043130
Hospital Charge Code	2500392
Hospital Revenue Code	250
Min. Negotiated Rate	$194.91
Max. Negotiated Rate	$378.14
Rate for Payer: AlohaCare Medicaid	$194.91
Rate for Payer: AlohaCare Medicare	$194.91
Rate for Payer: Cash Price	$253.39
Rate for Payer: Devoted Health Medicare	$214.41
Rate for Payer: Hawaii Medical Service Association Medicare	$194.91
Rate for Payer: Hawaii Western Management Group Commercial	$370.34
Rate for Payer: Health Management Network Commercial	$331.36
Rate for Payer: Humana Medicare	$194.91
Rate for Payer: Kaiser Permanente Commercial	$350.85
Rate for Payer: Kaiser Permanente Medicaid	$198.81
Rate for Payer: Kaiser Permanente Medicare	$194.91
Rate for Payer: MDX Hawaii PPO	$378.14
Rate for Payer: Ohana Health Plan Medicaid	$194.91
Rate for Payer: Ohana Health Plan Medicare	$194.91
Rate for Payer: UnitedHealthcare Medicaid	$233.90
Rate for Payer: UnitedHealthcare Medicare	$194.91
Rate for Payer: University Health Alliance Commercial	$284.15

hydrocortisone 2.5% cream rectal [HHSC]

Facility

$404.34

Service Code	NDC 64980032430
Hospital Charge Code	2500392
Hospital Revenue Code	250
Min. Negotiated Rate	$343.69
Max. Negotiated Rate	$392.21
Rate for Payer: Cash Price	$262.82
Rate for Payer: Health Management Network Commercial	$343.69
Rate for Payer: Kaiser Permanente Commercial	$363.91
Rate for Payer: MDX Hawaii PPO	$392.21

hydrocortisone 2.5% cream rectal [HHSC]

Facility

$389.83

Service Code	NDC 62559043130
Hospital Charge Code	2500392
Hospital Revenue Code	250
Min. Negotiated Rate	$331.36
Max. Negotiated Rate	$378.14
Rate for Payer: Cash Price	$253.39
Rate for Payer: Health Management Network Commercial	$331.36
Rate for Payer: Kaiser Permanente Commercial	$350.85
Rate for Payer: MDX Hawaii PPO	$378.14

hydrocortisone 2.5% cream rectal [HHSC]

Facility

$404.34

Service Code	NDC 64980032430
Hospital Charge Code	2500392
Hospital Revenue Code	250
Min. Negotiated Rate	$202.17
Max. Negotiated Rate	$392.21
Rate for Payer: AlohaCare Medicaid	$202.17
Rate for Payer: AlohaCare Medicare	$202.17
Rate for Payer: Cash Price	$262.82
Rate for Payer: Devoted Health Medicare	$222.39
Rate for Payer: Hawaii Medical Service Association Medicare	$202.17
Rate for Payer: Hawaii Western Management Group Commercial	$384.12
Rate for Payer: Health Management Network Commercial	$343.69
Rate for Payer: Humana Medicare	$202.17
Rate for Payer: Kaiser Permanente Commercial	$363.91
Rate for Payer: Kaiser Permanente Medicaid	$206.21
Rate for Payer: Kaiser Permanente Medicare	$202.17
Rate for Payer: MDX Hawaii PPO	$392.21
Rate for Payer: Ohana Health Plan Medicaid	$202.17
Rate for Payer: Ohana Health Plan Medicare	$202.17
Rate for Payer: UnitedHealthcare Medicaid	$242.60
Rate for Payer: UnitedHealthcare Medicare	$202.17
Rate for Payer: University Health Alliance Commercial	$294.72

hydrogen peroxide 3% 473 mL [HHSC]

Facility

$49.27

Service Code	NDC 00869470610
Hospital Charge Code	2500397
Hospital Revenue Code	250
Min. Negotiated Rate	$41.88
Max. Negotiated Rate	$47.79
Rate for Payer: Cash Price	$32.03
Rate for Payer: Health Management Network Commercial	$41.88
Rate for Payer: Kaiser Permanente Commercial	$44.34
Rate for Payer: MDX Hawaii PPO	$47.79

hydrogen peroxide 3% 473 mL [HHSC]

Facility

$49.27

Service Code	NDC 00869470610
Hospital Charge Code	2500397
Hospital Revenue Code	250
Min. Negotiated Rate	$24.64
Max. Negotiated Rate	$47.79
Rate for Payer: AlohaCare Medicaid	$24.64
Rate for Payer: AlohaCare Medicare	$24.64
Rate for Payer: Cash Price	$32.03
Rate for Payer: Devoted Health Medicare	$27.10
Rate for Payer: Hawaii Medical Service Association Medicare	$24.64
Rate for Payer: Hawaii Western Management Group Commercial	$46.81
Rate for Payer: Health Management Network Commercial	$41.88
Rate for Payer: Humana Medicare	$24.64
Rate for Payer: Kaiser Permanente Commercial	$44.34
Rate for Payer: Kaiser Permanente Medicaid	$25.13
Rate for Payer: Kaiser Permanente Medicare	$24.64
Rate for Payer: MDX Hawaii PPO	$47.79
Rate for Payer: Ohana Health Plan Medicaid	$24.64
Rate for Payer: Ohana Health Plan Medicare	$24.64
Rate for Payer: UnitedHealthcare Medicaid	$29.56
Rate for Payer: UnitedHealthcare Medicare	$24.64
Rate for Payer: University Health Alliance Commercial	$35.91

hydrogen peroxide 3% 473 mL [HHSC]

Facility

$11.07

Service Code	NDC 46122077334
Hospital Charge Code	2500397
Hospital Revenue Code	250
Min. Negotiated Rate	$9.41
Max. Negotiated Rate	$10.74
Rate for Payer: Cash Price	$7.20
Rate for Payer: Health Management Network Commercial	$9.41
Rate for Payer: Kaiser Permanente Commercial	$9.96
Rate for Payer: MDX Hawaii PPO	$10.74

Know your out-of-pocket cost for care.

All Charges