Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

OT Work Reconditioning init Assist Units

Facility

$307.00

Service Code	HCPCS 97545 GO,CO
Hospital Charge Code	8744684
Hospital Revenue Code	430
Min. Negotiated Rate	$260.95
Max. Negotiated Rate	$297.79
Rate for Payer: Cash Price	$199.55
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: MDX Hawaii PPO	$297.79

OT Work Reconditioning init Assist Units

Facility

$307.00

Service Code	HCPCS 97545 GO,CO
Hospital Charge Code	8744684
Hospital Revenue Code	430
Min. Negotiated Rate	$153.50
Max. Negotiated Rate	$297.79
Rate for Payer: AlohaCare Medicaid	$153.50
Rate for Payer: AlohaCare Medicare	$153.50
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$168.85
Rate for Payer: Hawaii Medical Service Association Medicare	$153.50
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Humana Medicare	$153.50
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: Kaiser Permanente Medicare	$153.50
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: Ohana Health Plan Medicaid	$153.50
Rate for Payer: Ohana Health Plan Medicare	$153.50
Rate for Payer: UnitedHealthcare Medicare	$153.50
Rate for Payer: University Health Alliance Commercial	$171.92

Ova and Parasites FSI

Facility

$129.00

Service Code	HCPCS 87177
Hospital Charge Code	8118007
Hospital Revenue Code	306
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$83.85
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: MDX Hawaii PPO	$125.13

Ova and Parasites FSI

Facility

$129.00

Service Code	HCPCS 87177
Hospital Charge Code	8118007
Hospital Revenue Code	306
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$64.50
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Devoted Health Medicare	$70.95
Rate for Payer: Hawaii Medical Service Association ABD	$12.30
Rate for Payer: Hawaii Medical Service Association Commercial	$11.12
Rate for Payer: Hawaii Medical Service Association Medicare	$64.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.92
Rate for Payer: Hawaii Western Management Group Commercial	$8.90
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$64.50
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$64.50
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$64.50
Rate for Payer: Ohana Health Plan Medicare	$64.50
Rate for Payer: UnitedHealthcare Medicaid	$12.30
Rate for Payer: UnitedHealthcare Medicare	$64.50
Rate for Payer: University Health Alliance Commercial	$23.00

Oxalate, Urine FSI

Facility

$147.00

Service Code	HCPCS 83945
Hospital Charge Code	8228905
Hospital Revenue Code	301
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

Oxalate, Urine FSI

Facility

$147.00

Service Code	HCPCS 83945
Hospital Charge Code	8228905
Hospital Revenue Code	301
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.80
Rate for Payer: Hawaii Medical Service Association Commercial	$18.06
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.69
Rate for Payer: Hawaii Western Management Group Commercial	$14.45
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$17.80
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$33.28

Oxcarbazepine Metabolite, Trileptal, Monohydroxycarbazepine FSI

Facility

$157.00

Service Code	HCPCS 80183
Hospital Charge Code	8118008
Hospital Revenue Code	301
Min. Negotiated Rate	$133.45
Max. Negotiated Rate	$152.29
Rate for Payer: Cash Price	$102.05
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: MDX Hawaii PPO	$152.29

Oxcarbazepine Metabolite, Trileptal, Monohydroxycarbazepine FSI

Facility

$157.00

Service Code	HCPCS 80183
Hospital Charge Code	8118008
Hospital Revenue Code	301
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$152.29
Rate for Payer: AlohaCare Medicaid	$78.50
Rate for Payer: AlohaCare Medicare	$78.50
Rate for Payer: Cash Price	$102.05
Rate for Payer: Cash Price	$102.05
Rate for Payer: Devoted Health Medicare	$86.35
Rate for Payer: Hawaii Medical Service Association ABD	$11.11
Rate for Payer: Hawaii Medical Service Association Commercial	$16.56
Rate for Payer: Hawaii Medical Service Association Medicare	$78.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.75
Rate for Payer: Hawaii Western Management Group Commercial	$13.25
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Humana Medicare	$78.50
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: Kaiser Permanente Medicaid	$80.07
Rate for Payer: Kaiser Permanente Medicare	$78.50
Rate for Payer: MDX Hawaii PPO	$152.29
Rate for Payer: Ohana Health Plan Medicaid	$78.50
Rate for Payer: Ohana Health Plan Medicare	$78.50
Rate for Payer: UnitedHealthcare Medicaid	$10.85
Rate for Payer: UnitedHealthcare Medicare	$78.50
Rate for Payer: University Health Alliance Commercial	$33.47

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 14539065301
Hospital Charge Code	2500621
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

oxybutynin 5 mg tablet [HHSC]

Facility

$4.23

Service Code	NDC 10702020101
Hospital Charge Code	2500621
Hospital Revenue Code	250
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$4.10
Rate for Payer: AlohaCare Medicaid	$2.12
Rate for Payer: AlohaCare Medicare	$2.12
Rate for Payer: Cash Price	$2.75
Rate for Payer: Devoted Health Medicare	$2.33
Rate for Payer: Hawaii Medical Service Association Medicare	$2.12
Rate for Payer: Hawaii Western Management Group Commercial	$4.02
Rate for Payer: Health Management Network Commercial	$3.60
Rate for Payer: Humana Medicare	$2.12
Rate for Payer: Kaiser Permanente Commercial	$3.81
Rate for Payer: Kaiser Permanente Medicaid	$2.16
Rate for Payer: Kaiser Permanente Medicare	$2.12
Rate for Payer: MDX Hawaii PPO	$4.10
Rate for Payer: Ohana Health Plan Medicaid	$2.12
Rate for Payer: Ohana Health Plan Medicare	$2.12
Rate for Payer: UnitedHealthcare Medicaid	$2.54
Rate for Payer: UnitedHealthcare Medicare	$2.12
Rate for Payer: University Health Alliance Commercial	$3.08

oxybutynin 5 mg tablet [HHSC]

Facility

$4.23

Service Code	NDC 10702020101
Hospital Charge Code	2500621
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$2.75
Rate for Payer: Health Management Network Commercial	$3.60
Rate for Payer: Kaiser Permanente Commercial	$3.81
Rate for Payer: MDX Hawaii PPO	$4.10

oxybutynin 5 mg tablet [HHSC]

Facility

$3.64

Service Code	NDC 00904282161
Hospital Charge Code	2500621
Hospital Revenue Code	250
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$3.53
Rate for Payer: AlohaCare Medicaid	$1.82
Rate for Payer: AlohaCare Medicare	$1.82
Rate for Payer: Cash Price	$2.37
Rate for Payer: Devoted Health Medicare	$2.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1.82
Rate for Payer: Hawaii Western Management Group Commercial	$3.46
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: Humana Medicare	$1.82
Rate for Payer: Kaiser Permanente Commercial	$3.28
Rate for Payer: Kaiser Permanente Medicaid	$1.86
Rate for Payer: Kaiser Permanente Medicare	$1.82
Rate for Payer: MDX Hawaii PPO	$3.53
Rate for Payer: Ohana Health Plan Medicaid	$1.82
Rate for Payer: Ohana Health Plan Medicare	$1.82
Rate for Payer: UnitedHealthcare Medicaid	$2.18
Rate for Payer: UnitedHealthcare Medicare	$1.82
Rate for Payer: University Health Alliance Commercial	$2.65

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 69315018201
Hospital Charge Code	2500621
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

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687067001
Hospital Charge Code	2500621
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

oxybutynin 5 mg tablet [HHSC]

Facility

$3.64

Service Code	NDC 00904282161
Hospital Charge Code	2500621
Hospital Revenue Code	250
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$3.53
Rate for Payer: Cash Price	$2.37
Rate for Payer: Health Management Network Commercial	$3.09
Rate for Payer: Kaiser Permanente Commercial	$3.28
Rate for Payer: MDX Hawaii PPO	$3.53

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084040001
Hospital Charge Code	2500621
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

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687067001
Hospital Charge Code	2500621
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

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 14539065301
Hospital Charge Code	2500621
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

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 69315018201
Hospital Charge Code	2500621
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

oxybutynin 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 68084040001
Hospital Charge Code	2500621
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

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.61

Service Code	NDC 00406051201
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$7.38
Rate for Payer: AlohaCare Medicaid	$3.81
Rate for Payer: AlohaCare Medicare	$3.81
Rate for Payer: Cash Price	$4.95
Rate for Payer: Devoted Health Medicare	$4.19
Rate for Payer: Hawaii Medical Service Association Medicare	$3.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.23
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Humana Medicare	$3.81
Rate for Payer: Kaiser Permanente Commercial	$6.85
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: Kaiser Permanente Medicare	$3.81
Rate for Payer: MDX Hawaii PPO	$7.38
Rate for Payer: Ohana Health Plan Medicaid	$3.81
Rate for Payer: Ohana Health Plan Medicare	$3.81
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: UnitedHealthcare Medicare	$3.81
Rate for Payer: University Health Alliance Commercial	$5.55

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.70

Service Code	NDC 68084035501
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$7.47
Rate for Payer: AlohaCare Medicaid	$3.85
Rate for Payer: AlohaCare Medicare	$3.85
Rate for Payer: Cash Price	$5.00
Rate for Payer: Devoted Health Medicare	$4.24
Rate for Payer: Hawaii Medical Service Association Medicare	$3.85
Rate for Payer: Hawaii Western Management Group Commercial	$7.32
Rate for Payer: Health Management Network Commercial	$6.54
Rate for Payer: Humana Medicare	$3.85
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: Kaiser Permanente Medicaid	$3.93
Rate for Payer: Kaiser Permanente Medicare	$3.85
Rate for Payer: MDX Hawaii PPO	$7.47
Rate for Payer: Ohana Health Plan Medicaid	$3.85
Rate for Payer: Ohana Health Plan Medicare	$3.85
Rate for Payer: UnitedHealthcare Medicaid	$4.62
Rate for Payer: UnitedHealthcare Medicare	$3.85
Rate for Payer: University Health Alliance Commercial	$5.61

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.61

Service Code	NDC 00406051262
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$7.38
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: AlohaCare Medicaid	$3.81
Rate for Payer: AlohaCare Medicare	$3.81
Rate for Payer: Cash Price	$4.95
Rate for Payer: Devoted Health Medicare	$4.19
Rate for Payer: Hawaii Medical Service Association Medicare	$3.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.23
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Humana Medicare	$3.81
Rate for Payer: Kaiser Permanente Commercial	$6.85
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: Kaiser Permanente Medicare	$3.81
Rate for Payer: MDX Hawaii PPO	$7.38
Rate for Payer: Ohana Health Plan Medicaid	$3.81
Rate for Payer: Ohana Health Plan Medicare	$3.81
Rate for Payer: UnitedHealthcare Medicare	$3.81
Rate for Payer: University Health Alliance Commercial	$5.55

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.61

Service Code	NDC 42858010201
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$7.38
Rate for Payer: AlohaCare Medicaid	$3.81
Rate for Payer: AlohaCare Medicare	$3.81
Rate for Payer: Cash Price	$4.95
Rate for Payer: Devoted Health Medicare	$4.19
Rate for Payer: Hawaii Medical Service Association Medicare	$3.81
Rate for Payer: Hawaii Western Management Group Commercial	$7.23
Rate for Payer: Health Management Network Commercial	$6.47
Rate for Payer: Humana Medicare	$3.81
Rate for Payer: Kaiser Permanente Commercial	$6.85
Rate for Payer: Kaiser Permanente Medicaid	$3.88
Rate for Payer: Kaiser Permanente Medicare	$3.81
Rate for Payer: MDX Hawaii PPO	$7.38
Rate for Payer: Ohana Health Plan Medicaid	$3.81
Rate for Payer: Ohana Health Plan Medicare	$3.81
Rate for Payer: UnitedHealthcare Medicaid	$4.57
Rate for Payer: UnitedHealthcare Medicare	$3.81
Rate for Payer: University Health Alliance Commercial	$5.55

oxyCODONE-APAP 5-325 mg tablet [HHSC]

Facility

$7.70

Service Code	NDC 68084035501
Hospital Charge Code	2500012
Hospital Revenue Code	250
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$7.47
Rate for Payer: Cash Price	$5.00
Rate for Payer: Health Management Network Commercial	$6.54
Rate for Payer: Kaiser Permanente Commercial	$6.93
Rate for Payer: MDX Hawaii PPO	$7.47

Know your out-of-pocket cost for care.

All Charges