Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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

$9.39

Service Code	NDC 13811071910
Hospital Charge Code	2500585
Hospital Revenue Code	250
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$9.11
Rate for Payer: Cash Price	$6.10
Rate for Payer: Health Management Network Commercial	$7.98
Rate for Payer: Kaiser Permanente Commercial	$8.45
Rate for Payer: MDX Hawaii PPO	$9.11

nitroglycerin 2% ointment 1gm [HHSC]

Facility

$13.94

Service Code	NDC 00281032608
Hospital Charge Code	2500589
Hospital Revenue Code	250
Min. Negotiated Rate	$11.85
Max. Negotiated Rate	$13.52
Rate for Payer: Cash Price	$9.06
Rate for Payer: Health Management Network Commercial	$11.85
Rate for Payer: Kaiser Permanente Commercial	$12.55
Rate for Payer: MDX Hawaii PPO	$13.52

nitroglycerin 2% ointment 1gm [HHSC]

Facility

$13.94

Service Code	NDC 00281032608
Hospital Charge Code	2500589
Hospital Revenue Code	250
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$13.52
Rate for Payer: AlohaCare Medicaid	$6.97
Rate for Payer: AlohaCare Medicare	$6.97
Rate for Payer: Cash Price	$9.06
Rate for Payer: Devoted Health Medicare	$7.67
Rate for Payer: Hawaii Medical Service Association Medicare	$6.97
Rate for Payer: Hawaii Western Management Group Commercial	$13.24
Rate for Payer: Health Management Network Commercial	$11.85
Rate for Payer: Humana Medicare	$6.97
Rate for Payer: Kaiser Permanente Commercial	$12.55
Rate for Payer: Kaiser Permanente Medicaid	$7.11
Rate for Payer: Kaiser Permanente Medicare	$6.97
Rate for Payer: MDX Hawaii PPO	$13.52
Rate for Payer: Ohana Health Plan Medicaid	$6.97
Rate for Payer: Ohana Health Plan Medicare	$6.97
Rate for Payer: UnitedHealthcare Medicaid	$8.36
Rate for Payer: UnitedHealthcare Medicare	$6.97
Rate for Payer: University Health Alliance Commercial	$10.16

nitroglycerin-d5w 0.2 mg/ml 250ml [HHSC]

Facility

$115.08

Service Code	NDC 00338104902
Hospital Charge Code	2500591
Hospital Revenue Code	250
Min. Negotiated Rate	$57.54
Max. Negotiated Rate	$111.63
Rate for Payer: AlohaCare Medicaid	$57.54
Rate for Payer: AlohaCare Medicare	$57.54
Rate for Payer: Cash Price	$74.80
Rate for Payer: Devoted Health Medicare	$63.29
Rate for Payer: Hawaii Medical Service Association Medicare	$57.54
Rate for Payer: Hawaii Western Management Group Commercial	$109.33
Rate for Payer: Health Management Network Commercial	$97.82
Rate for Payer: Humana Medicare	$57.54
Rate for Payer: Kaiser Permanente Commercial	$103.57
Rate for Payer: Kaiser Permanente Medicaid	$58.69
Rate for Payer: Kaiser Permanente Medicare	$57.54
Rate for Payer: MDX Hawaii PPO	$111.63
Rate for Payer: Ohana Health Plan Medicaid	$57.54
Rate for Payer: Ohana Health Plan Medicare	$57.54
Rate for Payer: UnitedHealthcare Medicaid	$69.05
Rate for Payer: UnitedHealthcare Medicare	$57.54
Rate for Payer: University Health Alliance Commercial	$83.88

nitroglycerin-d5w 0.2 mg/ml 250ml [HHSC]

Facility

$115.08

Service Code	NDC 00338104902
Hospital Charge Code	2500591
Hospital Revenue Code	250
Min. Negotiated Rate	$97.82
Max. Negotiated Rate	$111.63
Rate for Payer: Cash Price	$74.80
Rate for Payer: Health Management Network Commercial	$97.82
Rate for Payer: Kaiser Permanente Commercial	$103.57
Rate for Payer: MDX Hawaii PPO	$111.63

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$148.65

Service Code	NDC 00071041813
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$126.35
Max. Negotiated Rate	$144.19
Rate for Payer: Cash Price	$96.62
Rate for Payer: Health Management Network Commercial	$126.35
Rate for Payer: Kaiser Permanente Commercial	$133.78
Rate for Payer: MDX Hawaii PPO	$144.19

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 68462063945
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$121.70
Rate for Payer: AlohaCare Medicaid	$62.73
Rate for Payer: AlohaCare Medicare	$62.73
Rate for Payer: Cash Price	$81.55
Rate for Payer: Devoted Health Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Medicare	$62.73
Rate for Payer: Hawaii Western Management Group Commercial	$119.19
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Humana Medicare	$62.73
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: Kaiser Permanente Medicaid	$63.98
Rate for Payer: Kaiser Permanente Medicare	$62.73
Rate for Payer: MDX Hawaii PPO	$121.70
Rate for Payer: Ohana Health Plan Medicaid	$62.73
Rate for Payer: Ohana Health Plan Medicare	$62.73
Rate for Payer: UnitedHealthcare Medicaid	$75.28
Rate for Payer: UnitedHealthcare Medicare	$62.73
Rate for Payer: University Health Alliance Commercial	$91.45

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 70756001402
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$121.70
Rate for Payer: AlohaCare Medicaid	$62.73
Rate for Payer: AlohaCare Medicare	$62.73
Rate for Payer: Cash Price	$81.55
Rate for Payer: Devoted Health Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Medicare	$62.73
Rate for Payer: Hawaii Western Management Group Commercial	$119.19
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Humana Medicare	$62.73
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: Kaiser Permanente Medicaid	$63.98
Rate for Payer: Kaiser Permanente Medicare	$62.73
Rate for Payer: MDX Hawaii PPO	$121.70
Rate for Payer: Ohana Health Plan Medicaid	$62.73
Rate for Payer: Ohana Health Plan Medicare	$62.73
Rate for Payer: UnitedHealthcare Medicaid	$75.28
Rate for Payer: UnitedHealthcare Medicare	$62.73
Rate for Payer: University Health Alliance Commercial	$91.45

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 70756001402
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$106.64
Max. Negotiated Rate	$121.70
Rate for Payer: Cash Price	$81.55
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: MDX Hawaii PPO	$121.70

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$148.65

Service Code	NDC 00071041813
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$74.33
Max. Negotiated Rate	$144.19
Rate for Payer: UnitedHealthcare Medicaid	$89.19
Rate for Payer: AlohaCare Medicaid	$74.33
Rate for Payer: AlohaCare Medicare	$74.33
Rate for Payer: Cash Price	$96.62
Rate for Payer: Devoted Health Medicare	$81.76
Rate for Payer: Hawaii Medical Service Association Medicare	$74.33
Rate for Payer: Hawaii Western Management Group Commercial	$141.22
Rate for Payer: Health Management Network Commercial	$126.35
Rate for Payer: Humana Medicare	$74.33
Rate for Payer: Kaiser Permanente Commercial	$133.78
Rate for Payer: Kaiser Permanente Medicaid	$75.81
Rate for Payer: Kaiser Permanente Medicare	$74.33
Rate for Payer: MDX Hawaii PPO	$144.19
Rate for Payer: Ohana Health Plan Medicaid	$74.33
Rate for Payer: Ohana Health Plan Medicare	$74.33
Rate for Payer: UnitedHealthcare Medicare	$74.33
Rate for Payer: University Health Alliance Commercial	$108.35

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 59762330403
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$106.64
Max. Negotiated Rate	$121.70
Rate for Payer: Cash Price	$81.55
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: MDX Hawaii PPO	$121.70

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 59762330403
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$62.73
Max. Negotiated Rate	$121.70
Rate for Payer: AlohaCare Medicaid	$62.73
Rate for Payer: AlohaCare Medicare	$62.73
Rate for Payer: Cash Price	$81.55
Rate for Payer: Devoted Health Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Medicare	$62.73
Rate for Payer: Hawaii Western Management Group Commercial	$119.19
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Humana Medicare	$62.73
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: Kaiser Permanente Medicaid	$63.98
Rate for Payer: Kaiser Permanente Medicare	$62.73
Rate for Payer: MDX Hawaii PPO	$121.70
Rate for Payer: Ohana Health Plan Medicaid	$62.73
Rate for Payer: Ohana Health Plan Medicare	$62.73
Rate for Payer: UnitedHealthcare Medicaid	$75.28
Rate for Payer: UnitedHealthcare Medicare	$62.73
Rate for Payer: University Health Alliance Commercial	$91.45

nitroglycerin SL 0.4 mg tablet [HHSC]

Facility

$125.46

Service Code	NDC 68462063945
Hospital Charge Code	2500587
Hospital Revenue Code	250
Min. Negotiated Rate	$106.64
Max. Negotiated Rate	$121.70
Rate for Payer: Cash Price	$81.55
Rate for Payer: Health Management Network Commercial	$106.64
Rate for Payer: Kaiser Permanente Commercial	$112.91
Rate for Payer: MDX Hawaii PPO	$121.70

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$477.12

Service Code	NDC 42571026575
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$238.56
Max. Negotiated Rate	$462.81
Rate for Payer: AlohaCare Medicaid	$238.56
Rate for Payer: AlohaCare Medicare	$238.56
Rate for Payer: Cash Price	$310.13
Rate for Payer: Devoted Health Medicare	$262.42
Rate for Payer: Hawaii Medical Service Association Medicare	$238.56
Rate for Payer: Hawaii Western Management Group Commercial	$453.26
Rate for Payer: Health Management Network Commercial	$405.55
Rate for Payer: Humana Medicare	$238.56
Rate for Payer: Kaiser Permanente Commercial	$429.41
Rate for Payer: Kaiser Permanente Medicaid	$243.33
Rate for Payer: Kaiser Permanente Medicare	$238.56
Rate for Payer: MDX Hawaii PPO	$462.81
Rate for Payer: Ohana Health Plan Medicaid	$238.56
Rate for Payer: Ohana Health Plan Medicare	$238.56
Rate for Payer: UnitedHealthcare Medicaid	$286.27
Rate for Payer: UnitedHealthcare Medicare	$238.56
Rate for Payer: University Health Alliance Commercial	$347.77

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$122.65

Service Code	NDC 70069026101
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$104.25
Max. Negotiated Rate	$118.97
Rate for Payer: Cash Price	$79.72
Rate for Payer: Health Management Network Commercial	$104.25
Rate for Payer: Kaiser Permanente Commercial	$110.39
Rate for Payer: MDX Hawaii PPO	$118.97

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$118.47

Service Code	NDC 43598058723
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$59.23
Max. Negotiated Rate	$114.92
Rate for Payer: AlohaCare Medicaid	$59.23
Rate for Payer: AlohaCare Medicare	$59.23
Rate for Payer: Cash Price	$77.01
Rate for Payer: Devoted Health Medicare	$65.16
Rate for Payer: Hawaii Medical Service Association Medicare	$59.23
Rate for Payer: Hawaii Western Management Group Commercial	$112.55
Rate for Payer: Health Management Network Commercial	$100.70
Rate for Payer: Humana Medicare	$59.23
Rate for Payer: Kaiser Permanente Commercial	$106.62
Rate for Payer: Kaiser Permanente Medicaid	$60.42
Rate for Payer: Kaiser Permanente Medicare	$59.23
Rate for Payer: MDX Hawaii PPO	$114.92
Rate for Payer: Ohana Health Plan Medicaid	$59.23
Rate for Payer: Ohana Health Plan Medicare	$59.23
Rate for Payer: UnitedHealthcare Medicaid	$71.08
Rate for Payer: UnitedHealthcare Medicare	$59.23
Rate for Payer: University Health Alliance Commercial	$86.35

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$122.65

Service Code	NDC 70069026101
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$61.33
Max. Negotiated Rate	$118.97
Rate for Payer: AlohaCare Medicaid	$61.33
Rate for Payer: AlohaCare Medicare	$61.33
Rate for Payer: Cash Price	$79.72
Rate for Payer: Devoted Health Medicare	$67.46
Rate for Payer: Hawaii Medical Service Association Medicare	$61.33
Rate for Payer: Hawaii Western Management Group Commercial	$116.52
Rate for Payer: Health Management Network Commercial	$104.25
Rate for Payer: Humana Medicare	$61.33
Rate for Payer: Kaiser Permanente Commercial	$110.39
Rate for Payer: Kaiser Permanente Medicaid	$62.55
Rate for Payer: Kaiser Permanente Medicare	$61.33
Rate for Payer: MDX Hawaii PPO	$118.97
Rate for Payer: Ohana Health Plan Medicaid	$61.33
Rate for Payer: Ohana Health Plan Medicare	$61.33
Rate for Payer: UnitedHealthcare Medicaid	$73.59
Rate for Payer: UnitedHealthcare Medicare	$61.33
Rate for Payer: University Health Alliance Commercial	$89.40

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$568.04

Service Code	NDC 25021031002
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$284.02
Max. Negotiated Rate	$551.00
Rate for Payer: AlohaCare Medicaid	$284.02
Rate for Payer: AlohaCare Medicare	$284.02
Rate for Payer: Cash Price	$369.23
Rate for Payer: Devoted Health Medicare	$312.42
Rate for Payer: Hawaii Medical Service Association Medicare	$284.02
Rate for Payer: Hawaii Western Management Group Commercial	$539.64
Rate for Payer: Health Management Network Commercial	$482.83
Rate for Payer: Humana Medicare	$284.02
Rate for Payer: Kaiser Permanente Commercial	$511.24
Rate for Payer: Kaiser Permanente Medicaid	$289.70
Rate for Payer: Kaiser Permanente Medicare	$284.02
Rate for Payer: MDX Hawaii PPO	$551.00
Rate for Payer: Ohana Health Plan Medicaid	$284.02
Rate for Payer: Ohana Health Plan Medicare	$284.02
Rate for Payer: UnitedHealthcare Medicaid	$340.82
Rate for Payer: UnitedHealthcare Medicare	$284.02
Rate for Payer: University Health Alliance Commercial	$414.04

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$447.59

Service Code	NDC 25021031066
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$223.79
Max. Negotiated Rate	$434.16
Rate for Payer: AlohaCare Medicaid	$223.79
Rate for Payer: AlohaCare Medicare	$223.79
Rate for Payer: Cash Price	$290.93
Rate for Payer: Devoted Health Medicare	$246.17
Rate for Payer: Hawaii Medical Service Association Medicare	$223.79
Rate for Payer: Hawaii Western Management Group Commercial	$425.21
Rate for Payer: Health Management Network Commercial	$380.45
Rate for Payer: Humana Medicare	$223.79
Rate for Payer: Kaiser Permanente Commercial	$402.83
Rate for Payer: Kaiser Permanente Medicaid	$228.27
Rate for Payer: Kaiser Permanente Medicare	$223.79
Rate for Payer: MDX Hawaii PPO	$434.16
Rate for Payer: Ohana Health Plan Medicaid	$223.79
Rate for Payer: Ohana Health Plan Medicare	$223.79
Rate for Payer: UnitedHealthcare Medicaid	$268.55
Rate for Payer: UnitedHealthcare Medicare	$223.79
Rate for Payer: University Health Alliance Commercial	$326.25

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$568.04

Service Code	NDC 25021031002
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$482.83
Max. Negotiated Rate	$551.00
Rate for Payer: Cash Price	$369.23
Rate for Payer: Health Management Network Commercial	$482.83
Rate for Payer: Kaiser Permanente Commercial	$511.24
Rate for Payer: MDX Hawaii PPO	$551.00

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$188.19

Service Code	NDC 72485010501
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$159.96
Max. Negotiated Rate	$182.54
Rate for Payer: Cash Price	$122.32
Rate for Payer: Health Management Network Commercial	$159.96
Rate for Payer: Kaiser Permanente Commercial	$169.37
Rate for Payer: MDX Hawaii PPO	$182.54

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$447.59

Service Code	NDC 25021031066
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$380.45
Max. Negotiated Rate	$434.16
Rate for Payer: Cash Price	$290.93
Rate for Payer: Health Management Network Commercial	$380.45
Rate for Payer: Kaiser Permanente Commercial	$402.83
Rate for Payer: MDX Hawaii PPO	$434.16

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$477.12

Service Code	NDC 42571026575
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$405.55
Max. Negotiated Rate	$462.81
Rate for Payer: Cash Price	$310.13
Rate for Payer: Health Management Network Commercial	$405.55
Rate for Payer: Kaiser Permanente Commercial	$429.41
Rate for Payer: MDX Hawaii PPO	$462.81

nitroprusside 50 mg/2 ml vial [HHSC]

Facility

$188.19

Service Code	NDC 72485010501
Hospital Charge Code	2500592
Hospital Revenue Code	250
Min. Negotiated Rate	$94.09
Max. Negotiated Rate	$182.54
Rate for Payer: AlohaCare Medicaid	$94.09
Rate for Payer: AlohaCare Medicare	$94.09
Rate for Payer: Cash Price	$122.32
Rate for Payer: Devoted Health Medicare	$103.50
Rate for Payer: Hawaii Medical Service Association Medicare	$94.09
Rate for Payer: Hawaii Western Management Group Commercial	$178.78
Rate for Payer: Health Management Network Commercial	$159.96
Rate for Payer: Humana Medicare	$94.09
Rate for Payer: Kaiser Permanente Commercial	$169.37
Rate for Payer: Kaiser Permanente Medicaid	$95.98
Rate for Payer: Kaiser Permanente Medicare	$94.09
Rate for Payer: MDX Hawaii PPO	$182.54
Rate for Payer: Ohana Health Plan Medicaid	$94.09
Rate for Payer: Ohana Health Plan Medicare	$94.09
Rate for Payer: UnitedHealthcare Medicaid	$112.91
Rate for Payer: UnitedHealthcare Medicare	$94.09
Rate for Payer: University Health Alliance Commercial	$137.17

Know your out-of-pocket cost for care.

All Charges