Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

ticagrelor 60 mg tablet [HHSC]

Facility

$53.63

Service Code	NDC 00186077660
Hospital Charge Code	2501161
Hospital Revenue Code	250
Min. Negotiated Rate	$26.82
Max. Negotiated Rate	$52.02
Rate for Payer: AlohaCare Medicaid	$26.82
Rate for Payer: AlohaCare Medicare	$26.82
Rate for Payer: Cash Price	$34.86
Rate for Payer: Devoted Health Medicare	$29.50
Rate for Payer: Hawaii Medical Service Association Medicare	$26.82
Rate for Payer: Hawaii Western Management Group Commercial	$50.95
Rate for Payer: Health Management Network Commercial	$45.59
Rate for Payer: Humana Medicare	$26.82
Rate for Payer: Kaiser Permanente Commercial	$48.27
Rate for Payer: Kaiser Permanente Medicaid	$27.35
Rate for Payer: Kaiser Permanente Medicare	$26.82
Rate for Payer: MDX Hawaii PPO	$52.02
Rate for Payer: Ohana Health Plan Medicaid	$26.82
Rate for Payer: Ohana Health Plan Medicare	$26.82
Rate for Payer: UnitedHealthcare Medicaid	$32.18
Rate for Payer: UnitedHealthcare Medicare	$26.82
Rate for Payer: University Health Alliance Commercial	$39.09

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$89.21

Service Code	NDC 64980051405
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$44.60
Max. Negotiated Rate	$86.53
Rate for Payer: AlohaCare Medicaid	$44.60
Rate for Payer: AlohaCare Medicare	$44.60
Rate for Payer: Cash Price	$57.99
Rate for Payer: Devoted Health Medicare	$49.07
Rate for Payer: Hawaii Medical Service Association Medicare	$44.60
Rate for Payer: Hawaii Western Management Group Commercial	$84.75
Rate for Payer: Health Management Network Commercial	$75.83
Rate for Payer: Humana Medicare	$44.60
Rate for Payer: Kaiser Permanente Commercial	$80.29
Rate for Payer: Kaiser Permanente Medicaid	$45.50
Rate for Payer: Kaiser Permanente Medicare	$44.60
Rate for Payer: MDX Hawaii PPO	$86.53
Rate for Payer: Ohana Health Plan Medicaid	$44.60
Rate for Payer: Ohana Health Plan Medicare	$44.60
Rate for Payer: UnitedHealthcare Medicaid	$53.53
Rate for Payer: UnitedHealthcare Medicare	$44.60
Rate for Payer: University Health Alliance Commercial	$65.03

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$89.21

Service Code	NDC 17478028810
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$44.60
Max. Negotiated Rate	$86.53
Rate for Payer: AlohaCare Medicaid	$44.60
Rate for Payer: AlohaCare Medicare	$44.60
Rate for Payer: Cash Price	$57.99
Rate for Payer: Devoted Health Medicare	$49.07
Rate for Payer: Hawaii Medical Service Association Medicare	$44.60
Rate for Payer: Hawaii Western Management Group Commercial	$84.75
Rate for Payer: Health Management Network Commercial	$75.83
Rate for Payer: Humana Medicare	$44.60
Rate for Payer: Kaiser Permanente Commercial	$80.29
Rate for Payer: Kaiser Permanente Medicaid	$45.50
Rate for Payer: Kaiser Permanente Medicare	$44.60
Rate for Payer: MDX Hawaii PPO	$86.53
Rate for Payer: Ohana Health Plan Medicaid	$44.60
Rate for Payer: Ohana Health Plan Medicare	$44.60
Rate for Payer: UnitedHealthcare Medicaid	$53.53
Rate for Payer: UnitedHealthcare Medicare	$44.60
Rate for Payer: University Health Alliance Commercial	$65.03

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$89.21

Service Code	NDC 17478028810
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$75.83
Max. Negotiated Rate	$86.53
Rate for Payer: Cash Price	$57.99
Rate for Payer: Health Management Network Commercial	$75.83
Rate for Payer: Kaiser Permanente Commercial	$80.29
Rate for Payer: MDX Hawaii PPO	$86.53

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$41.63

Service Code	NDC 60758080105
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$20.82
Max. Negotiated Rate	$40.38
Rate for Payer: AlohaCare Medicaid	$20.82
Rate for Payer: AlohaCare Medicare	$20.82
Rate for Payer: Cash Price	$27.06
Rate for Payer: Devoted Health Medicare	$22.90
Rate for Payer: Hawaii Medical Service Association Medicare	$20.82
Rate for Payer: Hawaii Western Management Group Commercial	$39.55
Rate for Payer: Health Management Network Commercial	$35.39
Rate for Payer: Humana Medicare	$20.82
Rate for Payer: Kaiser Permanente Commercial	$37.47
Rate for Payer: Kaiser Permanente Medicaid	$21.23
Rate for Payer: Kaiser Permanente Medicare	$20.82
Rate for Payer: MDX Hawaii PPO	$40.38
Rate for Payer: Ohana Health Plan Medicaid	$20.82
Rate for Payer: Ohana Health Plan Medicare	$20.82
Rate for Payer: UnitedHealthcare Medicaid	$24.98
Rate for Payer: UnitedHealthcare Medicare	$20.82
Rate for Payer: University Health Alliance Commercial	$30.34

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$41.63

Service Code	NDC 60758080105
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$35.39
Max. Negotiated Rate	$40.38
Rate for Payer: Cash Price	$27.06
Rate for Payer: Health Management Network Commercial	$35.39
Rate for Payer: Kaiser Permanente Commercial	$37.47
Rate for Payer: MDX Hawaii PPO	$40.38

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$89.21

Service Code	NDC 61314022705
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$75.83
Max. Negotiated Rate	$86.53
Rate for Payer: Cash Price	$57.99
Rate for Payer: Health Management Network Commercial	$75.83
Rate for Payer: Kaiser Permanente Commercial	$80.29
Rate for Payer: MDX Hawaii PPO	$86.53

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$89.21

Service Code	NDC 61314022705
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$44.60
Max. Negotiated Rate	$86.53
Rate for Payer: AlohaCare Medicaid	$44.60
Rate for Payer: AlohaCare Medicare	$44.60
Rate for Payer: Cash Price	$57.99
Rate for Payer: Devoted Health Medicare	$49.07
Rate for Payer: Hawaii Medical Service Association Medicare	$44.60
Rate for Payer: Hawaii Western Management Group Commercial	$84.75
Rate for Payer: Health Management Network Commercial	$75.83
Rate for Payer: Humana Medicare	$44.60
Rate for Payer: Kaiser Permanente Commercial	$80.29
Rate for Payer: Kaiser Permanente Medicaid	$45.50
Rate for Payer: Kaiser Permanente Medicare	$44.60
Rate for Payer: MDX Hawaii PPO	$86.53
Rate for Payer: Ohana Health Plan Medicaid	$44.60
Rate for Payer: Ohana Health Plan Medicare	$44.60
Rate for Payer: UnitedHealthcare Medicaid	$53.53
Rate for Payer: UnitedHealthcare Medicare	$44.60
Rate for Payer: University Health Alliance Commercial	$65.03

timolol maleate 0.5% ophth drop 5mL [HHSC]

Facility

$89.21

Service Code	NDC 64980051405
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$75.83
Max. Negotiated Rate	$86.53
Rate for Payer: Cash Price	$57.99
Rate for Payer: Health Management Network Commercial	$75.83
Rate for Payer: Kaiser Permanente Commercial	$80.29
Rate for Payer: MDX Hawaii PPO	$86.53

TINE PLATE, 2.7MM, 10 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13001561
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

TINE PLATE, 2.7MM, 10 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13001561
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

TINE PLATE, 2.7MM, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000861
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

TINE PLATE, 2.7MM, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000861
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

TIP INTRAUTERINE MANIPULATOR 6.7MMX 10 CM

Facility

$261.00

Hospital Charge Code	9716417
Hospital Revenue Code	272
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$253.17
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$130.50
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$143.55
Rate for Payer: Hawaii Medical Service Association Medicare	$130.50
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$130.50
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicare	$130.50
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$130.50
Rate for Payer: Ohana Health Plan Medicare	$130.50
Rate for Payer: UnitedHealthcare Medicare	$130.50
Rate for Payer: University Health Alliance Commercial	$190.24

TIP INTRAUTERINE MANIPULATOR 6.7MMX 10 CM

Facility

$261.00

Hospital Charge Code	9716417
Hospital Revenue Code	272
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

TIP INTRAUTERINE MANIPULATOR 6.7MMX 12 CM ORANGE RUMI II SYSTEM

Facility

$261.00

Hospital Charge Code	9716418
Hospital Revenue Code	272
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

TIP INTRAUTERINE MANIPULATOR 6.7MMX 12 CM ORANGE RUMI II SYSTEM

Facility

$261.00

Hospital Charge Code	9716418
Hospital Revenue Code	272
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$253.17
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$130.50
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$143.55
Rate for Payer: Hawaii Medical Service Association Medicare	$130.50
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$130.50
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicare	$130.50
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$130.50
Rate for Payer: Ohana Health Plan Medicare	$130.50
Rate for Payer: UnitedHealthcare Medicare	$130.50
Rate for Payer: University Health Alliance Commercial	$190.24

TIP INTRAUTERINE MANIPULATOR 6.7MM X 6 CM

Facility

$261.00

Hospital Charge Code	9716415
Hospital Revenue Code	272
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$253.17
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$130.50
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$143.55
Rate for Payer: Hawaii Medical Service Association Medicare	$130.50
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$130.50
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicare	$130.50
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$130.50
Rate for Payer: Ohana Health Plan Medicare	$130.50
Rate for Payer: UnitedHealthcare Medicare	$130.50
Rate for Payer: University Health Alliance Commercial	$190.24

TIP INTRAUTERINE MANIPULATOR 6.7MM X 6 CM

Facility

$261.00

Hospital Charge Code	9716415
Hospital Revenue Code	272
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

TIP INTRAUTERINE MANIPULATOR 6.7MM X 8 CM

Facility

$288.00

Hospital Charge Code	9716416
Hospital Revenue Code	272
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$187.20
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: MDX Hawaii PPO	$279.36

TIP INTRAUTERINE MANIPULATOR 6.7MM X 8 CM

Facility

$288.00

Hospital Charge Code	9716416
Hospital Revenue Code	272
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$279.36
Rate for Payer: AlohaCare Medicaid	$144.00
Rate for Payer: AlohaCare Medicare	$144.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Devoted Health Medicare	$158.40
Rate for Payer: Hawaii Medical Service Association Medicare	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$273.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Humana Medicare	$144.00
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: Kaiser Permanente Medicare	$144.00
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: Ohana Health Plan Medicaid	$144.00
Rate for Payer: Ohana Health Plan Medicare	$144.00
Rate for Payer: UnitedHealthcare Medicare	$144.00
Rate for Payer: University Health Alliance Commercial	$209.92

TIP UTERINE MANIPULATOR 3.75CM

Facility

$356.00

Hospital Charge Code	9715513
Hospital Revenue Code	272
Min. Negotiated Rate	$178.00
Max. Negotiated Rate	$345.32
Rate for Payer: AlohaCare Medicaid	$178.00
Rate for Payer: AlohaCare Medicare	$178.00
Rate for Payer: Cash Price	$231.40
Rate for Payer: Devoted Health Medicare	$195.80
Rate for Payer: Hawaii Medical Service Association Medicare	$178.00
Rate for Payer: Hawaii Western Management Group Commercial	$338.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Humana Medicare	$178.00
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: Kaiser Permanente Medicaid	$181.56
Rate for Payer: Kaiser Permanente Medicare	$178.00
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: Ohana Health Plan Medicaid	$178.00
Rate for Payer: Ohana Health Plan Medicare	$178.00
Rate for Payer: UnitedHealthcare Medicare	$178.00
Rate for Payer: University Health Alliance Commercial	$259.49

TIP UTERINE MANIPULATOR 3.75CM

Facility

$356.00

Hospital Charge Code	9715513
Hospital Revenue Code	272
Min. Negotiated Rate	$302.60
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$231.40
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: MDX Hawaii PPO	$345.32

Tissue Transglutaminase Antibody IgA, tTG IgA, TG2 IgA, Native tTG, Human RGC Ttg FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8118060
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$678.03
Rate for Payer: AlohaCare Medicaid	$349.50
Rate for Payer: AlohaCare Medicare	$349.50
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Devoted Health Medicare	$384.45
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$349.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Humana Medicare	$349.50
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: Kaiser Permanente Medicaid	$356.49
Rate for Payer: Kaiser Permanente Medicare	$349.50
Rate for Payer: MDX Hawaii PPO	$678.03
Rate for Payer: Ohana Health Plan Medicaid	$349.50
Rate for Payer: Ohana Health Plan Medicare	$349.50
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$349.50
Rate for Payer: University Health Alliance Commercial	$29.82

Tissue Transglutaminase Antibody IgA, tTG IgA, TG2 IgA, Native tTG, Human RGC Ttg FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8118060
Hospital Revenue Code	301
Min. Negotiated Rate	$594.15
Max. Negotiated Rate	$678.03
Rate for Payer: Cash Price	$454.35
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: MDX Hawaii PPO	$678.03

Know your out-of-pocket cost for care.

All Charges