Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

LORazepam 2 mg tablet [HHSC]

Facility

$7.34

Service Code	NDC 51079038720
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$7.12
Rate for Payer: AlohaCare Medicaid	$3.67
Rate for Payer: AlohaCare Medicare	$3.67
Rate for Payer: Cash Price	$4.77
Rate for Payer: Devoted Health Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Medicare	$3.67
Rate for Payer: Hawaii Western Management Group Commercial	$6.97
Rate for Payer: Health Management Network Commercial	$6.24
Rate for Payer: Humana Medicare	$3.67
Rate for Payer: Kaiser Permanente Commercial	$6.61
Rate for Payer: Kaiser Permanente Medicaid	$3.74
Rate for Payer: Kaiser Permanente Medicare	$3.67
Rate for Payer: MDX Hawaii PPO	$7.12
Rate for Payer: Ohana Health Plan Medicaid	$3.67
Rate for Payer: Ohana Health Plan Medicare	$3.67
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: UnitedHealthcare Medicare	$3.67
Rate for Payer: University Health Alliance Commercial	$5.35

LORazepam 2 mg tablet [HHSC]

Facility

$7.34

Service Code	NDC 68084075401
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$7.12
Rate for Payer: Cash Price	$4.77
Rate for Payer: Health Management Network Commercial	$6.24
Rate for Payer: Kaiser Permanente Commercial	$6.61
Rate for Payer: MDX Hawaii PPO	$7.12

LORazepam 2 mg tablet [HHSC]

Facility

$7.34

Service Code	NDC 68084075401
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$7.12
Rate for Payer: AlohaCare Medicaid	$3.67
Rate for Payer: AlohaCare Medicare	$3.67
Rate for Payer: Cash Price	$4.77
Rate for Payer: Devoted Health Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Medicare	$3.67
Rate for Payer: Hawaii Western Management Group Commercial	$6.97
Rate for Payer: Health Management Network Commercial	$6.24
Rate for Payer: Humana Medicare	$3.67
Rate for Payer: Kaiser Permanente Commercial	$6.61
Rate for Payer: Kaiser Permanente Medicaid	$3.74
Rate for Payer: Kaiser Permanente Medicare	$3.67
Rate for Payer: MDX Hawaii PPO	$7.12
Rate for Payer: Ohana Health Plan Medicaid	$3.67
Rate for Payer: Ohana Health Plan Medicare	$3.67
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: UnitedHealthcare Medicare	$3.67
Rate for Payer: University Health Alliance Commercial	$5.35

LORazepam 2 mg tablet [HHSC]

Facility

$6.79

Service Code	NDC 69315090601
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$6.59
Rate for Payer: AlohaCare Medicaid	$3.40
Rate for Payer: AlohaCare Medicare	$3.40
Rate for Payer: Cash Price	$4.41
Rate for Payer: Devoted Health Medicare	$3.73
Rate for Payer: Hawaii Medical Service Association Medicare	$3.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.45
Rate for Payer: Health Management Network Commercial	$5.77
Rate for Payer: Humana Medicare	$3.40
Rate for Payer: Kaiser Permanente Commercial	$6.11
Rate for Payer: Kaiser Permanente Medicaid	$3.46
Rate for Payer: Kaiser Permanente Medicare	$3.40
Rate for Payer: MDX Hawaii PPO	$6.59
Rate for Payer: Ohana Health Plan Medicaid	$3.40
Rate for Payer: Ohana Health Plan Medicare	$3.40
Rate for Payer: UnitedHealthcare Medicaid	$4.07
Rate for Payer: UnitedHealthcare Medicare	$3.40
Rate for Payer: University Health Alliance Commercial	$4.95

LORazepam 2 mg tablet [HHSC]

Facility

$6.79

Service Code	NDC 69315090601
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$5.77
Max. Negotiated Rate	$6.59
Rate for Payer: Cash Price	$4.41
Rate for Payer: Health Management Network Commercial	$5.77
Rate for Payer: Kaiser Permanente Commercial	$6.11
Rate for Payer: MDX Hawaii PPO	$6.59

LORazepam 2 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687064901
Hospital Charge Code	2500500
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

LORazepam 2 mg tablet [HHSC]

Facility

$7.13

Service Code	NDC 00093342701
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$6.92
Rate for Payer: AlohaCare Medicaid	$3.56
Rate for Payer: AlohaCare Medicare	$3.56
Rate for Payer: Cash Price	$4.63
Rate for Payer: Devoted Health Medicare	$3.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3.56
Rate for Payer: Hawaii Western Management Group Commercial	$6.77
Rate for Payer: Health Management Network Commercial	$6.06
Rate for Payer: Humana Medicare	$3.56
Rate for Payer: Kaiser Permanente Commercial	$6.42
Rate for Payer: Kaiser Permanente Medicaid	$3.64
Rate for Payer: Kaiser Permanente Medicare	$3.56
Rate for Payer: MDX Hawaii PPO	$6.92
Rate for Payer: Ohana Health Plan Medicaid	$3.56
Rate for Payer: Ohana Health Plan Medicare	$3.56
Rate for Payer: UnitedHealthcare Medicaid	$4.28
Rate for Payer: UnitedHealthcare Medicare	$3.56
Rate for Payer: University Health Alliance Commercial	$5.20

LORazepam 2 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687064901
Hospital Charge Code	2500500
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

LORazepam 2 mg tablet [HHSC]

Facility

$7.13

Service Code	NDC 00591024201
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$6.92
Rate for Payer: AlohaCare Medicaid	$3.56
Rate for Payer: AlohaCare Medicare	$3.56
Rate for Payer: Cash Price	$4.63
Rate for Payer: Devoted Health Medicare	$3.92
Rate for Payer: Hawaii Medical Service Association Medicare	$3.56
Rate for Payer: Hawaii Western Management Group Commercial	$6.77
Rate for Payer: Health Management Network Commercial	$6.06
Rate for Payer: Humana Medicare	$3.56
Rate for Payer: Kaiser Permanente Commercial	$6.42
Rate for Payer: Kaiser Permanente Medicaid	$3.64
Rate for Payer: Kaiser Permanente Medicare	$3.56
Rate for Payer: MDX Hawaii PPO	$6.92
Rate for Payer: Ohana Health Plan Medicaid	$3.56
Rate for Payer: Ohana Health Plan Medicare	$3.56
Rate for Payer: UnitedHealthcare Medicaid	$4.28
Rate for Payer: UnitedHealthcare Medicare	$3.56
Rate for Payer: University Health Alliance Commercial	$5.20

LORazepam 2 mg tablet [HHSC]

Facility

$7.34

Service Code	NDC 60687036701
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$7.12
Rate for Payer: Cash Price	$4.77
Rate for Payer: Health Management Network Commercial	$6.24
Rate for Payer: Kaiser Permanente Commercial	$6.61
Rate for Payer: MDX Hawaii PPO	$7.12

LORazepam 2 mg tablet [HHSC]

Facility

$7.13

Service Code	NDC 00591024201
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$6.92
Rate for Payer: Cash Price	$4.63
Rate for Payer: Health Management Network Commercial	$6.06
Rate for Payer: Kaiser Permanente Commercial	$6.42
Rate for Payer: MDX Hawaii PPO	$6.92

LORazepam 2 mg tablet [HHSC]

Facility

$7.13

Service Code	NDC 00093342701
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$6.06
Max. Negotiated Rate	$6.92
Rate for Payer: Cash Price	$4.63
Rate for Payer: Health Management Network Commercial	$6.06
Rate for Payer: Kaiser Permanente Commercial	$6.42
Rate for Payer: MDX Hawaii PPO	$6.92

LORazepam 2 mg tablet [HHSC]

Facility

$7.34

Service Code	NDC 51079038720
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$7.12
Rate for Payer: Cash Price	$4.77
Rate for Payer: Health Management Network Commercial	$6.24
Rate for Payer: Kaiser Permanente Commercial	$6.61
Rate for Payer: MDX Hawaii PPO	$7.12

LORazepam 2 mg tablet [HHSC]

Facility

$7.34

Service Code	NDC 60687036701
Hospital Charge Code	2500500
Hospital Revenue Code	250
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$7.12
Rate for Payer: AlohaCare Medicaid	$3.67
Rate for Payer: AlohaCare Medicare	$3.67
Rate for Payer: Cash Price	$4.77
Rate for Payer: Devoted Health Medicare	$4.04
Rate for Payer: Hawaii Medical Service Association Medicare	$3.67
Rate for Payer: Hawaii Western Management Group Commercial	$6.97
Rate for Payer: Health Management Network Commercial	$6.24
Rate for Payer: Humana Medicare	$3.67
Rate for Payer: Kaiser Permanente Commercial	$6.61
Rate for Payer: Kaiser Permanente Medicaid	$3.74
Rate for Payer: Kaiser Permanente Medicare	$3.67
Rate for Payer: MDX Hawaii PPO	$7.12
Rate for Payer: Ohana Health Plan Medicaid	$3.67
Rate for Payer: Ohana Health Plan Medicare	$3.67
Rate for Payer: UnitedHealthcare Medicaid	$4.40
Rate for Payer: UnitedHealthcare Medicare	$3.67
Rate for Payer: University Health Alliance Commercial	$5.35

losartan 25 mg tablet [HHSC]

Facility

$9.33

Service Code	NDC 68084034601
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$7.93
Max. Negotiated Rate	$9.05
Rate for Payer: Cash Price	$6.06
Rate for Payer: Health Management Network Commercial	$7.93
Rate for Payer: Kaiser Permanente Commercial	$8.40
Rate for Payer: MDX Hawaii PPO	$9.05

losartan 25 mg tablet [HHSC]

Facility

$9.33

Service Code	NDC 68084034601
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$9.05
Rate for Payer: AlohaCare Medicaid	$4.67
Rate for Payer: AlohaCare Medicare	$4.67
Rate for Payer: Cash Price	$6.06
Rate for Payer: Devoted Health Medicare	$5.13
Rate for Payer: Hawaii Medical Service Association Medicare	$4.67
Rate for Payer: Hawaii Western Management Group Commercial	$8.86
Rate for Payer: Health Management Network Commercial	$7.93
Rate for Payer: Humana Medicare	$4.67
Rate for Payer: Kaiser Permanente Commercial	$8.40
Rate for Payer: Kaiser Permanente Medicaid	$4.76
Rate for Payer: Kaiser Permanente Medicare	$4.67
Rate for Payer: MDX Hawaii PPO	$9.05
Rate for Payer: Ohana Health Plan Medicaid	$4.67
Rate for Payer: Ohana Health Plan Medicare	$4.67
Rate for Payer: UnitedHealthcare Medicaid	$5.60
Rate for Payer: UnitedHealthcare Medicare	$4.67
Rate for Payer: University Health Alliance Commercial	$6.80

losartan 25 mg tablet [HHSC]

Facility

$9.36

Service Code	NDC 65862020190
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.08
Rate for Payer: AlohaCare Medicaid	$4.68
Rate for Payer: AlohaCare Medicare	$4.68
Rate for Payer: Cash Price	$6.08
Rate for Payer: Devoted Health Medicare	$5.15
Rate for Payer: Hawaii Medical Service Association Medicare	$4.68
Rate for Payer: Hawaii Western Management Group Commercial	$8.89
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: Humana Medicare	$4.68
Rate for Payer: Kaiser Permanente Commercial	$8.42
Rate for Payer: Kaiser Permanente Medicaid	$4.77
Rate for Payer: Kaiser Permanente Medicare	$4.68
Rate for Payer: MDX Hawaii PPO	$9.08
Rate for Payer: Ohana Health Plan Medicaid	$4.68
Rate for Payer: Ohana Health Plan Medicare	$4.68
Rate for Payer: UnitedHealthcare Medicaid	$5.62
Rate for Payer: UnitedHealthcare Medicare	$4.68
Rate for Payer: University Health Alliance Commercial	$6.82

losartan 25 mg tablet [HHSC]

Facility

$9.36

Service Code	NDC 65862020190
Hospital Charge Code	2500503
Hospital Revenue Code	250
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$6.08
Rate for Payer: Health Management Network Commercial	$7.96
Rate for Payer: Kaiser Permanente Commercial	$8.42
Rate for Payer: MDX Hawaii PPO	$9.08

losartan 50 mg tablet [HHSC]

Facility

$24.75

Service Code	NDC 00006095254
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$24.01
Rate for Payer: AlohaCare Medicaid	$12.38
Rate for Payer: AlohaCare Medicare	$12.38
Rate for Payer: Cash Price	$16.09
Rate for Payer: Devoted Health Medicare	$13.61
Rate for Payer: Hawaii Medical Service Association Medicare	$12.38
Rate for Payer: Hawaii Western Management Group Commercial	$23.51
Rate for Payer: Health Management Network Commercial	$21.04
Rate for Payer: Humana Medicare	$12.38
Rate for Payer: Kaiser Permanente Commercial	$22.27
Rate for Payer: Kaiser Permanente Medicaid	$12.62
Rate for Payer: Kaiser Permanente Medicare	$12.38
Rate for Payer: MDX Hawaii PPO	$24.01
Rate for Payer: Ohana Health Plan Medicaid	$12.38
Rate for Payer: Ohana Health Plan Medicare	$12.38
Rate for Payer: UnitedHealthcare Medicaid	$14.85
Rate for Payer: UnitedHealthcare Medicare	$12.38
Rate for Payer: University Health Alliance Commercial	$18.04

losartan 50 mg tablet [HHSC]

Facility

$12.58

Service Code	NDC 68180037703
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$12.20
Rate for Payer: AlohaCare Medicaid	$6.29
Rate for Payer: AlohaCare Medicare	$6.29
Rate for Payer: Cash Price	$8.18
Rate for Payer: Devoted Health Medicare	$6.92
Rate for Payer: Hawaii Medical Service Association Medicare	$6.29
Rate for Payer: Hawaii Western Management Group Commercial	$11.95
Rate for Payer: Health Management Network Commercial	$10.69
Rate for Payer: Humana Medicare	$6.29
Rate for Payer: Kaiser Permanente Commercial	$11.32
Rate for Payer: Kaiser Permanente Medicaid	$6.42
Rate for Payer: Kaiser Permanente Medicare	$6.29
Rate for Payer: MDX Hawaii PPO	$12.20
Rate for Payer: Ohana Health Plan Medicaid	$6.29
Rate for Payer: Ohana Health Plan Medicare	$6.29
Rate for Payer: UnitedHealthcare Medicaid	$7.55
Rate for Payer: UnitedHealthcare Medicare	$6.29
Rate for Payer: University Health Alliance Commercial	$9.17

losartan 50 mg tablet [HHSC]

Facility

$12.58

Service Code	NDC 68180037703
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$10.69
Max. Negotiated Rate	$12.20
Rate for Payer: Cash Price	$8.18
Rate for Payer: Health Management Network Commercial	$10.69
Rate for Payer: Kaiser Permanente Commercial	$11.32
Rate for Payer: MDX Hawaii PPO	$12.20

losartan 50 mg tablet [HHSC]

Facility

$12.51

Service Code	NDC 68084034701
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$12.13
Rate for Payer: Cash Price	$8.13
Rate for Payer: Health Management Network Commercial	$10.63
Rate for Payer: Kaiser Permanente Commercial	$11.26
Rate for Payer: MDX Hawaii PPO	$12.13

losartan 50 mg tablet [HHSC]

Facility

$12.51

Service Code	NDC 68084034701
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$6.25
Max. Negotiated Rate	$12.13
Rate for Payer: AlohaCare Medicaid	$6.25
Rate for Payer: AlohaCare Medicare	$6.25
Rate for Payer: Cash Price	$8.13
Rate for Payer: Devoted Health Medicare	$6.88
Rate for Payer: Hawaii Medical Service Association Medicare	$6.25
Rate for Payer: Hawaii Western Management Group Commercial	$11.88
Rate for Payer: Health Management Network Commercial	$10.63
Rate for Payer: Humana Medicare	$6.25
Rate for Payer: Kaiser Permanente Commercial	$11.26
Rate for Payer: Kaiser Permanente Medicaid	$6.38
Rate for Payer: Kaiser Permanente Medicare	$6.25
Rate for Payer: MDX Hawaii PPO	$12.13
Rate for Payer: Ohana Health Plan Medicaid	$6.25
Rate for Payer: Ohana Health Plan Medicare	$6.25
Rate for Payer: UnitedHealthcare Medicaid	$7.51
Rate for Payer: UnitedHealthcare Medicare	$6.25
Rate for Payer: University Health Alliance Commercial	$9.12

losartan 50 mg tablet [HHSC]

Facility

$24.75

Service Code	NDC 00006095254
Hospital Charge Code	2500504
Hospital Revenue Code	250
Min. Negotiated Rate	$21.04
Max. Negotiated Rate	$24.01
Rate for Payer: Cash Price	$16.09
Rate for Payer: Health Management Network Commercial	$21.04
Rate for Payer: Kaiser Permanente Commercial	$22.27
Rate for Payer: MDX Hawaii PPO	$24.01

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$54,751.62

Service Code	MSDRG 493
Min. Negotiated Rate	$54,751.62
Max. Negotiated Rate	$54,751.62
Rate for Payer: Hawaii Medical Service Association Commercial	$54,751.62

Know your out-of-pocket cost for care.

All Charges