Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.64

Service Code	NDC 46122035274
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$11.29
Rate for Payer: AlohaCare Medicaid	$5.82
Rate for Payer: AlohaCare Medicare	$5.82
Rate for Payer: Cash Price	$7.57
Rate for Payer: Devoted Health Medicare	$6.40
Rate for Payer: Hawaii Medical Service Association Medicare	$5.82
Rate for Payer: Hawaii Western Management Group Commercial	$11.06
Rate for Payer: Health Management Network Commercial	$9.89
Rate for Payer: Humana Medicare	$5.82
Rate for Payer: Kaiser Permanente Commercial	$10.48
Rate for Payer: Kaiser Permanente Medicaid	$5.94
Rate for Payer: Kaiser Permanente Medicare	$5.82
Rate for Payer: MDX Hawaii PPO	$11.29
Rate for Payer: Ohana Health Plan Medicaid	$5.82
Rate for Payer: Ohana Health Plan Medicare	$5.82
Rate for Payer: UnitedHealthcare Medicaid	$6.98
Rate for Payer: UnitedHealthcare Medicare	$5.82
Rate for Payer: University Health Alliance Commercial	$8.48

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 00536589588
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$11.55
Rate for Payer: AlohaCare Medicaid	$5.96
Rate for Payer: AlohaCare Medicare	$5.96
Rate for Payer: Cash Price	$7.74
Rate for Payer: Devoted Health Medicare	$6.55
Rate for Payer: Hawaii Medical Service Association Medicare	$5.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.31
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Humana Medicare	$5.96
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: Kaiser Permanente Medicaid	$6.07
Rate for Payer: Kaiser Permanente Medicare	$5.96
Rate for Payer: MDX Hawaii PPO	$11.55
Rate for Payer: Ohana Health Plan Medicaid	$5.96
Rate for Payer: Ohana Health Plan Medicare	$5.96
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$5.96
Rate for Payer: University Health Alliance Commercial	$8.68

nicotine 14 mg/24 hr patch [HHSC]

Facility

$11.86

Service Code	NDC 43598044774
Hospital Charge Code	2500580
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$11.50
Rate for Payer: Cash Price	$7.71
Rate for Payer: Health Management Network Commercial	$10.08
Rate for Payer: Kaiser Permanente Commercial	$10.67
Rate for Payer: MDX Hawaii PPO	$11.50

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.68

Service Code	NDC 46122035374
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$9.93
Max. Negotiated Rate	$11.33
Rate for Payer: Cash Price	$7.59
Rate for Payer: Health Management Network Commercial	$9.93
Rate for Payer: Kaiser Permanente Commercial	$10.51
Rate for Payer: MDX Hawaii PPO	$11.33

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 68001043490
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$11.55
Rate for Payer: AlohaCare Medicaid	$5.96
Rate for Payer: AlohaCare Medicare	$5.96
Rate for Payer: Cash Price	$7.74
Rate for Payer: Devoted Health Medicare	$6.55
Rate for Payer: Hawaii Medical Service Association Medicare	$5.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.31
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Humana Medicare	$5.96
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: Kaiser Permanente Medicaid	$6.07
Rate for Payer: Kaiser Permanente Medicare	$5.96
Rate for Payer: MDX Hawaii PPO	$11.55
Rate for Payer: Ohana Health Plan Medicaid	$5.96
Rate for Payer: Ohana Health Plan Medicare	$5.96
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$5.96
Rate for Payer: University Health Alliance Commercial	$8.68

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.86

Service Code	NDC 43598044874
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$11.50
Rate for Payer: Cash Price	$7.71
Rate for Payer: Health Management Network Commercial	$10.08
Rate for Payer: Kaiser Permanente Commercial	$10.67
Rate for Payer: MDX Hawaii PPO	$11.50

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.68

Service Code	NDC 46122035374
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$5.84
Max. Negotiated Rate	$11.33
Rate for Payer: AlohaCare Medicaid	$5.84
Rate for Payer: AlohaCare Medicare	$5.84
Rate for Payer: Cash Price	$7.59
Rate for Payer: Devoted Health Medicare	$6.42
Rate for Payer: Hawaii Medical Service Association Medicare	$5.84
Rate for Payer: Hawaii Western Management Group Commercial	$11.10
Rate for Payer: Health Management Network Commercial	$9.93
Rate for Payer: Humana Medicare	$5.84
Rate for Payer: Kaiser Permanente Commercial	$10.51
Rate for Payer: Kaiser Permanente Medicaid	$5.96
Rate for Payer: Kaiser Permanente Medicare	$5.84
Rate for Payer: MDX Hawaii PPO	$11.33
Rate for Payer: Ohana Health Plan Medicaid	$5.84
Rate for Payer: Ohana Health Plan Medicare	$5.84
Rate for Payer: UnitedHealthcare Medicaid	$7.01
Rate for Payer: UnitedHealthcare Medicare	$5.84
Rate for Payer: University Health Alliance Commercial	$8.51

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 00536589688
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$5.96
Max. Negotiated Rate	$11.55
Rate for Payer: AlohaCare Medicaid	$5.96
Rate for Payer: AlohaCare Medicare	$5.96
Rate for Payer: Cash Price	$7.74
Rate for Payer: Devoted Health Medicare	$6.55
Rate for Payer: Hawaii Medical Service Association Medicare	$5.96
Rate for Payer: Hawaii Western Management Group Commercial	$11.31
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Humana Medicare	$5.96
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: Kaiser Permanente Medicaid	$6.07
Rate for Payer: Kaiser Permanente Medicare	$5.96
Rate for Payer: MDX Hawaii PPO	$11.55
Rate for Payer: Ohana Health Plan Medicaid	$5.96
Rate for Payer: Ohana Health Plan Medicare	$5.96
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$5.96
Rate for Payer: University Health Alliance Commercial	$8.68

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.86

Service Code	NDC 43598044874
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$11.50
Rate for Payer: AlohaCare Medicaid	$5.93
Rate for Payer: AlohaCare Medicare	$5.93
Rate for Payer: Cash Price	$7.71
Rate for Payer: Devoted Health Medicare	$6.52
Rate for Payer: Hawaii Medical Service Association Medicare	$5.93
Rate for Payer: Hawaii Western Management Group Commercial	$11.27
Rate for Payer: Health Management Network Commercial	$10.08
Rate for Payer: Humana Medicare	$5.93
Rate for Payer: Kaiser Permanente Commercial	$10.67
Rate for Payer: Kaiser Permanente Medicaid	$6.05
Rate for Payer: Kaiser Permanente Medicare	$5.93
Rate for Payer: MDX Hawaii PPO	$11.50
Rate for Payer: Ohana Health Plan Medicaid	$5.93
Rate for Payer: Ohana Health Plan Medicare	$5.93
Rate for Payer: UnitedHealthcare Medicaid	$7.12
Rate for Payer: UnitedHealthcare Medicare	$5.93
Rate for Payer: University Health Alliance Commercial	$8.64

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 00536589688
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$10.12
Max. Negotiated Rate	$11.55
Rate for Payer: Cash Price	$7.74
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: MDX Hawaii PPO	$11.55

nicotine 21 mg/24 hr patch [HHSC]

Facility

$11.91

Service Code	NDC 68001043490
Hospital Charge Code	2500581
Hospital Revenue Code	250
Min. Negotiated Rate	$10.12
Max. Negotiated Rate	$11.55
Rate for Payer: Cash Price	$7.74
Rate for Payer: Health Management Network Commercial	$10.12
Rate for Payer: Kaiser Permanente Commercial	$10.72
Rate for Payer: MDX Hawaii PPO	$11.55

NIFEdipine ER 30 mg tablet [HHSC]

Facility

$7.75

Service Code	NDC 50742062001
Hospital Charge Code	2500583
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$7.52
Rate for Payer: Cash Price	$5.04
Rate for Payer: Health Management Network Commercial	$6.59
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: MDX Hawaii PPO	$7.52

NIFEdipine ER 30 mg tablet [HHSC]

Facility

$7.75

Service Code	NDC 00378035301
Hospital Charge Code	2500583
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$7.52
Rate for Payer: AlohaCare Medicaid	$3.88
Rate for Payer: AlohaCare Medicare	$3.88
Rate for Payer: Cash Price	$5.04
Rate for Payer: Devoted Health Medicare	$4.26
Rate for Payer: Hawaii Medical Service Association Medicare	$3.88
Rate for Payer: Hawaii Western Management Group Commercial	$7.36
Rate for Payer: Health Management Network Commercial	$6.59
Rate for Payer: Humana Medicare	$3.88
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: Kaiser Permanente Medicaid	$3.95
Rate for Payer: Kaiser Permanente Medicare	$3.88
Rate for Payer: MDX Hawaii PPO	$7.52
Rate for Payer: Ohana Health Plan Medicaid	$3.88
Rate for Payer: Ohana Health Plan Medicare	$3.88
Rate for Payer: UnitedHealthcare Medicaid	$4.65
Rate for Payer: UnitedHealthcare Medicare	$3.88
Rate for Payer: University Health Alliance Commercial	$5.65

NIFEdipine ER 30 mg tablet [HHSC]

Facility

$7.75

Service Code	NDC 00378035301
Hospital Charge Code	2500583
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$7.52
Rate for Payer: Cash Price	$5.04
Rate for Payer: Health Management Network Commercial	$6.59
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: MDX Hawaii PPO	$7.52

NIFEdipine ER 30 mg tablet [HHSC]

Facility

$7.75

Service Code	NDC 50742062001
Hospital Charge Code	2500583
Hospital Revenue Code	250
Min. Negotiated Rate	$3.88
Max. Negotiated Rate	$7.52
Rate for Payer: AlohaCare Medicaid	$3.88
Rate for Payer: AlohaCare Medicare	$3.88
Rate for Payer: Cash Price	$5.04
Rate for Payer: Devoted Health Medicare	$4.26
Rate for Payer: Hawaii Medical Service Association Medicare	$3.88
Rate for Payer: Hawaii Western Management Group Commercial	$7.36
Rate for Payer: Health Management Network Commercial	$6.59
Rate for Payer: Humana Medicare	$3.88
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: Kaiser Permanente Medicaid	$3.95
Rate for Payer: Kaiser Permanente Medicare	$3.88
Rate for Payer: MDX Hawaii PPO	$7.52
Rate for Payer: Ohana Health Plan Medicaid	$3.88
Rate for Payer: Ohana Health Plan Medicare	$3.88
Rate for Payer: UnitedHealthcare Medicaid	$4.65
Rate for Payer: UnitedHealthcare Medicare	$3.88
Rate for Payer: University Health Alliance Commercial	$5.65

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$14.36

Service Code	NDC 68084044601
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$7.18
Max. Negotiated Rate	$13.93
Rate for Payer: AlohaCare Medicaid	$7.18
Rate for Payer: AlohaCare Medicare	$7.18
Rate for Payer: Cash Price	$9.33
Rate for Payer: Devoted Health Medicare	$7.90
Rate for Payer: Hawaii Medical Service Association Medicare	$7.18
Rate for Payer: Hawaii Western Management Group Commercial	$13.64
Rate for Payer: Health Management Network Commercial	$12.21
Rate for Payer: Humana Medicare	$7.18
Rate for Payer: Kaiser Permanente Commercial	$12.92
Rate for Payer: Kaiser Permanente Medicaid	$7.32
Rate for Payer: Kaiser Permanente Medicare	$7.18
Rate for Payer: MDX Hawaii PPO	$13.93
Rate for Payer: Ohana Health Plan Medicaid	$7.18
Rate for Payer: Ohana Health Plan Medicare	$7.18
Rate for Payer: UnitedHealthcare Medicaid	$8.62
Rate for Payer: UnitedHealthcare Medicare	$7.18
Rate for Payer: University Health Alliance Commercial	$10.47

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$23.83

Service Code	NDC 60687063365
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$11.91
Max. Negotiated Rate	$23.12
Rate for Payer: AlohaCare Medicaid	$11.91
Rate for Payer: AlohaCare Medicare	$11.91
Rate for Payer: Cash Price	$15.49
Rate for Payer: Devoted Health Medicare	$13.11
Rate for Payer: Hawaii Medical Service Association Medicare	$11.91
Rate for Payer: Hawaii Western Management Group Commercial	$22.64
Rate for Payer: Health Management Network Commercial	$20.26
Rate for Payer: Humana Medicare	$11.91
Rate for Payer: Kaiser Permanente Commercial	$21.45
Rate for Payer: Kaiser Permanente Medicaid	$12.15
Rate for Payer: Kaiser Permanente Medicare	$11.91
Rate for Payer: MDX Hawaii PPO	$23.12
Rate for Payer: Ohana Health Plan Medicaid	$11.91
Rate for Payer: Ohana Health Plan Medicare	$11.91
Rate for Payer: UnitedHealthcare Medicaid	$14.30
Rate for Payer: UnitedHealthcare Medicare	$11.91
Rate for Payer: University Health Alliance Commercial	$17.37

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$14.36

Service Code	NDC 68084044601
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$13.93
Rate for Payer: Cash Price	$9.33
Rate for Payer: Health Management Network Commercial	$12.21
Rate for Payer: Kaiser Permanente Commercial	$12.92
Rate for Payer: MDX Hawaii PPO	$13.93

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$20.94

Service Code	NDC 68001000100
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$17.80
Max. Negotiated Rate	$20.31
Rate for Payer: Cash Price	$13.61
Rate for Payer: Health Management Network Commercial	$17.80
Rate for Payer: Kaiser Permanente Commercial	$18.85
Rate for Payer: MDX Hawaii PPO	$20.31

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$22.70

Service Code	NDC 70756040411
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$11.35
Max. Negotiated Rate	$22.02
Rate for Payer: AlohaCare Medicaid	$11.35
Rate for Payer: AlohaCare Medicare	$11.35
Rate for Payer: Cash Price	$14.76
Rate for Payer: Devoted Health Medicare	$12.48
Rate for Payer: Hawaii Medical Service Association Medicare	$11.35
Rate for Payer: Hawaii Western Management Group Commercial	$21.57
Rate for Payer: Health Management Network Commercial	$19.30
Rate for Payer: Humana Medicare	$11.35
Rate for Payer: Kaiser Permanente Commercial	$20.43
Rate for Payer: Kaiser Permanente Medicaid	$11.58
Rate for Payer: Kaiser Permanente Medicare	$11.35
Rate for Payer: MDX Hawaii PPO	$22.02
Rate for Payer: Ohana Health Plan Medicaid	$11.35
Rate for Payer: Ohana Health Plan Medicare	$11.35
Rate for Payer: UnitedHealthcare Medicaid	$13.62
Rate for Payer: UnitedHealthcare Medicare	$11.35
Rate for Payer: University Health Alliance Commercial	$16.55

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$20.94

Service Code	NDC 68001042300
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$20.31
Rate for Payer: AlohaCare Medicaid	$10.47
Rate for Payer: AlohaCare Medicare	$10.47
Rate for Payer: Cash Price	$13.61
Rate for Payer: Devoted Health Medicare	$11.52
Rate for Payer: Hawaii Medical Service Association Medicare	$10.47
Rate for Payer: Hawaii Western Management Group Commercial	$19.89
Rate for Payer: Health Management Network Commercial	$17.80
Rate for Payer: Humana Medicare	$10.47
Rate for Payer: Kaiser Permanente Commercial	$18.85
Rate for Payer: Kaiser Permanente Medicaid	$10.68
Rate for Payer: Kaiser Permanente Medicare	$10.47
Rate for Payer: MDX Hawaii PPO	$20.31
Rate for Payer: Ohana Health Plan Medicaid	$10.47
Rate for Payer: Ohana Health Plan Medicare	$10.47
Rate for Payer: UnitedHealthcare Medicaid	$12.56
Rate for Payer: UnitedHealthcare Medicare	$10.47
Rate for Payer: University Health Alliance Commercial	$15.26

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$23.83

Service Code	NDC 60687063365
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$20.26
Max. Negotiated Rate	$23.12
Rate for Payer: Cash Price	$15.49
Rate for Payer: Health Management Network Commercial	$20.26
Rate for Payer: Kaiser Permanente Commercial	$21.45
Rate for Payer: MDX Hawaii PPO	$23.12

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$9.39

Service Code	NDC 13811071910
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$9.11
Rate for Payer: AlohaCare Medicaid	$4.70
Rate for Payer: AlohaCare Medicare	$4.70
Rate for Payer: Cash Price	$6.10
Rate for Payer: Devoted Health Medicare	$5.16
Rate for Payer: Hawaii Medical Service Association Medicare	$4.70
Rate for Payer: Hawaii Western Management Group Commercial	$8.92
Rate for Payer: Health Management Network Commercial	$7.98
Rate for Payer: Humana Medicare	$4.70
Rate for Payer: Kaiser Permanente Commercial	$8.45
Rate for Payer: Kaiser Permanente Medicaid	$4.79
Rate for Payer: Kaiser Permanente Medicare	$4.70
Rate for Payer: MDX Hawaii PPO	$9.11
Rate for Payer: Ohana Health Plan Medicaid	$4.70
Rate for Payer: Ohana Health Plan Medicare	$4.70
Rate for Payer: UnitedHealthcare Medicaid	$5.63
Rate for Payer: UnitedHealthcare Medicare	$4.70
Rate for Payer: University Health Alliance Commercial	$6.84

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$22.70

Service Code	NDC 70756040411
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$19.30
Max. Negotiated Rate	$22.02
Rate for Payer: Cash Price	$14.76
Rate for Payer: Health Management Network Commercial	$19.30
Rate for Payer: Kaiser Permanente Commercial	$20.43
Rate for Payer: MDX Hawaii PPO	$22.02

nitrofurantoin macr-mon 100 mg capsule [HHSC]

Facility

$20.94

Service Code	NDC 68001000100
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$20.31
Rate for Payer: AlohaCare Medicaid	$10.47
Rate for Payer: AlohaCare Medicare	$10.47
Rate for Payer: Cash Price	$13.61
Rate for Payer: Devoted Health Medicare	$11.52
Rate for Payer: Hawaii Medical Service Association Medicare	$10.47
Rate for Payer: Hawaii Western Management Group Commercial	$19.89
Rate for Payer: Health Management Network Commercial	$17.80
Rate for Payer: Humana Medicare	$10.47
Rate for Payer: Kaiser Permanente Commercial	$18.85
Rate for Payer: Kaiser Permanente Medicaid	$10.68
Rate for Payer: Kaiser Permanente Medicare	$10.47
Rate for Payer: MDX Hawaii PPO	$20.31
Rate for Payer: Ohana Health Plan Medicaid	$10.47
Rate for Payer: Ohana Health Plan Medicare	$10.47
Rate for Payer: UnitedHealthcare Medicaid	$12.56
Rate for Payer: UnitedHealthcare Medicare	$10.47
Rate for Payer: University Health Alliance Commercial	$15.26

Know your out-of-pocket cost for care.

All Charges