Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

TRAY WET SKIN PREP TRAY WITH PVP BOTTLE

Facility

$22.00

Hospital Charge Code	8266593
Hospital Revenue Code	272
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$21.34
Rate for Payer: AlohaCare Medicaid	$11.00
Rate for Payer: AlohaCare Medicare	$11.00
Rate for Payer: Cash Price	$14.30
Rate for Payer: Devoted Health Medicare	$12.10
Rate for Payer: Hawaii Medical Service Association Medicare	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Humana Medicare	$11.00
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: Kaiser Permanente Medicare	$11.00
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: Ohana Health Plan Medicaid	$11.00
Rate for Payer: Ohana Health Plan Medicare	$11.00
Rate for Payer: UnitedHealthcare Medicare	$11.00
Rate for Payer: University Health Alliance Commercial	$16.04

TRAY WET SKIN PREP TRAY WITH PVP BOTTLE

Facility

$22.00

Hospital Charge Code	8266593
Hospital Revenue Code	272
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$14.30
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$19.80
Rate for Payer: MDX Hawaii PPO	$21.34

traZODone 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904686961
Hospital Charge Code	2500832
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

traZODone 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687045401
Hospital Charge Code	2500832
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

traZODone 100 mg tablet [HHSC]

Facility

$7.74

Service Code	NDC 50111043401
Hospital Charge Code	2500832
Hospital Revenue Code	250
Min. Negotiated Rate	$6.58
Max. Negotiated Rate	$7.51
Rate for Payer: Cash Price	$5.03
Rate for Payer: Health Management Network Commercial	$6.58
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: MDX Hawaii PPO	$7.51

traZODone 100 mg tablet [HHSC]

Facility

$4.36

Service Code	NDC 00904655561
Hospital Charge Code	2500832
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$4.23
Rate for Payer: AlohaCare Medicaid	$2.18
Rate for Payer: AlohaCare Medicare	$2.18
Rate for Payer: Cash Price	$2.83
Rate for Payer: Devoted Health Medicare	$2.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2.18
Rate for Payer: Hawaii Western Management Group Commercial	$4.14
Rate for Payer: Health Management Network Commercial	$3.71
Rate for Payer: Humana Medicare	$2.18
Rate for Payer: Kaiser Permanente Commercial	$3.92
Rate for Payer: Kaiser Permanente Medicaid	$2.22
Rate for Payer: Kaiser Permanente Medicare	$2.18
Rate for Payer: MDX Hawaii PPO	$4.23
Rate for Payer: Ohana Health Plan Medicaid	$2.18
Rate for Payer: Ohana Health Plan Medicare	$2.18
Rate for Payer: UnitedHealthcare Medicaid	$2.62
Rate for Payer: UnitedHealthcare Medicare	$2.18
Rate for Payer: University Health Alliance Commercial	$3.18

traZODone 100 mg tablet [HHSC]

Facility

$7.74

Service Code	NDC 50111043401
Hospital Charge Code	2500832
Hospital Revenue Code	250
Min. Negotiated Rate	$3.87
Max. Negotiated Rate	$7.51
Rate for Payer: AlohaCare Medicaid	$3.87
Rate for Payer: AlohaCare Medicare	$3.87
Rate for Payer: Cash Price	$5.03
Rate for Payer: Devoted Health Medicare	$4.26
Rate for Payer: Hawaii Medical Service Association Medicare	$3.87
Rate for Payer: Hawaii Western Management Group Commercial	$7.35
Rate for Payer: Health Management Network Commercial	$6.58
Rate for Payer: Humana Medicare	$3.87
Rate for Payer: Kaiser Permanente Commercial	$6.97
Rate for Payer: Kaiser Permanente Medicaid	$3.95
Rate for Payer: Kaiser Permanente Medicare	$3.87
Rate for Payer: MDX Hawaii PPO	$7.51
Rate for Payer: Ohana Health Plan Medicaid	$3.87
Rate for Payer: Ohana Health Plan Medicare	$3.87
Rate for Payer: UnitedHealthcare Medicaid	$4.64
Rate for Payer: UnitedHealthcare Medicare	$3.87
Rate for Payer: University Health Alliance Commercial	$5.64

traZODone 100 mg tablet [HHSC]

Facility

$4.36

Service Code	NDC 00904655561
Hospital Charge Code	2500832
Hospital Revenue Code	250
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$4.23
Rate for Payer: Cash Price	$2.83
Rate for Payer: Health Management Network Commercial	$3.71
Rate for Payer: Kaiser Permanente Commercial	$3.92
Rate for Payer: MDX Hawaii PPO	$4.23

traZODone 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687045401
Hospital Charge Code	2500832
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

traZODone 100 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904686961
Hospital Charge Code	2500832
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

traZODone 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687044301
Hospital Charge Code	2500833
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

traZODone 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904686861
Hospital Charge Code	2500833
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

traZODone 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 60687044301
Hospital Charge Code	2500833
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

traZODone 50 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904686861
Hospital Charge Code	2500833
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

Treatment of Swallowing Dysfunction Charge

Facility

$533.00

Service Code	HCPCS 92526
Hospital Charge Code	8177255
Hospital Revenue Code	440
Min. Negotiated Rate	$22.46
Max. Negotiated Rate	$517.01
Rate for Payer: AlohaCare Medicaid	$266.50
Rate for Payer: AlohaCare Medicare	$266.50
Rate for Payer: Cash Price	$346.45
Rate for Payer: Cash Price	$346.45
Rate for Payer: Devoted Health Medicare	$293.15
Rate for Payer: Hawaii Medical Service Association Medicare	$266.50
Rate for Payer: Hawaii Western Management Group Commercial	$506.35
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Humana Medicare	$266.50
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: Kaiser Permanente Medicaid	$271.83
Rate for Payer: Kaiser Permanente Medicare	$266.50
Rate for Payer: MDX Hawaii PPO	$517.01
Rate for Payer: Ohana Health Plan Medicaid	$266.50
Rate for Payer: Ohana Health Plan Medicare	$266.50
Rate for Payer: UnitedHealthcare Medicaid	$22.46
Rate for Payer: UnitedHealthcare Medicare	$266.50
Rate for Payer: University Health Alliance Commercial	$298.48

Treatment of Swallowing Dysfunction Charge

Facility

$533.00

Service Code	HCPCS 92526
Hospital Charge Code	8177255
Hospital Revenue Code	440
Min. Negotiated Rate	$453.05
Max. Negotiated Rate	$517.01
Rate for Payer: Cash Price	$346.45
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: MDX Hawaii PPO	$517.01

Treatment of Swallowing Dysfunction Charge

Facility

$533.00

Service Code	HCPCS 92526 GP,CQ
Hospital Charge Code	8171650
Hospital Revenue Code	440
Min. Negotiated Rate	$453.05
Max. Negotiated Rate	$517.01
Rate for Payer: Cash Price	$346.45
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: MDX Hawaii PPO	$517.01

Treatment of Swallowing Dysfunction Charge

Facility

$533.00

Service Code	HCPCS 92526 GP,CQ
Hospital Charge Code	8171650
Hospital Revenue Code	440
Min. Negotiated Rate	$22.46
Max. Negotiated Rate	$517.01
Rate for Payer: AlohaCare Medicaid	$266.50
Rate for Payer: AlohaCare Medicare	$266.50
Rate for Payer: Cash Price	$346.45
Rate for Payer: Cash Price	$346.45
Rate for Payer: Devoted Health Medicare	$293.15
Rate for Payer: Hawaii Medical Service Association Medicare	$266.50
Rate for Payer: Hawaii Western Management Group Commercial	$506.35
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Humana Medicare	$266.50
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: Kaiser Permanente Medicaid	$271.83
Rate for Payer: Kaiser Permanente Medicare	$266.50
Rate for Payer: MDX Hawaii PPO	$517.01
Rate for Payer: Ohana Health Plan Medicaid	$266.50
Rate for Payer: Ohana Health Plan Medicare	$266.50
Rate for Payer: UnitedHealthcare Medicaid	$22.46
Rate for Payer: UnitedHealthcare Medicare	$266.50
Rate for Payer: University Health Alliance Commercial	$298.48

triamcinolone 0.1% cream 15gm [HHSC]

Facility

$32.41

Service Code	NDC 67877025115
Hospital Charge Code	2500837
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$31.44
Rate for Payer: AlohaCare Medicaid	$16.20
Rate for Payer: AlohaCare Medicare	$16.20
Rate for Payer: Cash Price	$21.07
Rate for Payer: Devoted Health Medicare	$17.83
Rate for Payer: Hawaii Medical Service Association Medicare	$16.20
Rate for Payer: Hawaii Western Management Group Commercial	$30.79
Rate for Payer: Health Management Network Commercial	$27.55
Rate for Payer: Humana Medicare	$16.20
Rate for Payer: Kaiser Permanente Commercial	$29.17
Rate for Payer: Kaiser Permanente Medicaid	$16.53
Rate for Payer: Kaiser Permanente Medicare	$16.20
Rate for Payer: MDX Hawaii PPO	$31.44
Rate for Payer: Ohana Health Plan Medicaid	$16.20
Rate for Payer: Ohana Health Plan Medicare	$16.20
Rate for Payer: UnitedHealthcare Medicaid	$19.45
Rate for Payer: UnitedHealthcare Medicare	$16.20
Rate for Payer: University Health Alliance Commercial	$23.62

triamcinolone 0.1% cream 15gm [HHSC]

Facility

$30.58

Service Code	NDC 33342032915
Hospital Charge Code	2500837
Hospital Revenue Code	250
Min. Negotiated Rate	$15.29
Max. Negotiated Rate	$29.66
Rate for Payer: AlohaCare Medicaid	$15.29
Rate for Payer: AlohaCare Medicare	$15.29
Rate for Payer: Cash Price	$19.88
Rate for Payer: Devoted Health Medicare	$16.82
Rate for Payer: Hawaii Medical Service Association Medicare	$15.29
Rate for Payer: Hawaii Western Management Group Commercial	$29.05
Rate for Payer: Health Management Network Commercial	$25.99
Rate for Payer: Humana Medicare	$15.29
Rate for Payer: Kaiser Permanente Commercial	$27.52
Rate for Payer: Kaiser Permanente Medicaid	$15.60
Rate for Payer: Kaiser Permanente Medicare	$15.29
Rate for Payer: MDX Hawaii PPO	$29.66
Rate for Payer: Ohana Health Plan Medicaid	$15.29
Rate for Payer: Ohana Health Plan Medicare	$15.29
Rate for Payer: UnitedHealthcare Medicaid	$18.35
Rate for Payer: UnitedHealthcare Medicare	$15.29
Rate for Payer: University Health Alliance Commercial	$22.29

triamcinolone 0.1% cream 15gm [HHSC]

Facility

$32.30

Service Code	NDC 00168000415
Hospital Charge Code	2500837
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$31.33
Rate for Payer: AlohaCare Medicaid	$16.15
Rate for Payer: AlohaCare Medicare	$16.15
Rate for Payer: Cash Price	$20.99
Rate for Payer: Devoted Health Medicare	$17.77
Rate for Payer: Hawaii Medical Service Association Medicare	$16.15
Rate for Payer: Hawaii Western Management Group Commercial	$30.68
Rate for Payer: Health Management Network Commercial	$27.45
Rate for Payer: Humana Medicare	$16.15
Rate for Payer: Kaiser Permanente Commercial	$29.07
Rate for Payer: Kaiser Permanente Medicaid	$16.47
Rate for Payer: Kaiser Permanente Medicare	$16.15
Rate for Payer: MDX Hawaii PPO	$31.33
Rate for Payer: Ohana Health Plan Medicaid	$16.15
Rate for Payer: Ohana Health Plan Medicare	$16.15
Rate for Payer: UnitedHealthcare Medicaid	$19.38
Rate for Payer: UnitedHealthcare Medicare	$16.15
Rate for Payer: University Health Alliance Commercial	$23.54

triamcinolone 0.1% cream 15gm [HHSC]

Facility

$32.30

Service Code	NDC 00168000415
Hospital Charge Code	2500837
Hospital Revenue Code	250
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$31.33
Rate for Payer: Cash Price	$20.99
Rate for Payer: Health Management Network Commercial	$27.45
Rate for Payer: Kaiser Permanente Commercial	$29.07
Rate for Payer: MDX Hawaii PPO	$31.33

triamcinolone 0.1% cream 15gm [HHSC]

Facility

$32.41

Service Code	NDC 67877025115
Hospital Charge Code	2500837
Hospital Revenue Code	250
Min. Negotiated Rate	$27.55
Max. Negotiated Rate	$31.44
Rate for Payer: Cash Price	$21.07
Rate for Payer: Health Management Network Commercial	$27.55
Rate for Payer: Kaiser Permanente Commercial	$29.17
Rate for Payer: MDX Hawaii PPO	$31.44

triamcinolone 0.1% cream 15gm [HHSC]

Facility

$21.63

Service Code	NDC 45802006435
Hospital Charge Code	2500837
Hospital Revenue Code	250
Min. Negotiated Rate	$10.81
Max. Negotiated Rate	$20.98
Rate for Payer: AlohaCare Medicaid	$10.81
Rate for Payer: AlohaCare Medicare	$10.81
Rate for Payer: Cash Price	$14.06
Rate for Payer: Devoted Health Medicare	$11.90
Rate for Payer: Hawaii Medical Service Association Medicare	$10.81
Rate for Payer: Hawaii Western Management Group Commercial	$20.55
Rate for Payer: Health Management Network Commercial	$18.39
Rate for Payer: Humana Medicare	$10.81
Rate for Payer: Kaiser Permanente Commercial	$19.47
Rate for Payer: Kaiser Permanente Medicaid	$11.03
Rate for Payer: Kaiser Permanente Medicare	$10.81
Rate for Payer: MDX Hawaii PPO	$20.98
Rate for Payer: Ohana Health Plan Medicaid	$10.81
Rate for Payer: Ohana Health Plan Medicare	$10.81
Rate for Payer: UnitedHealthcare Medicaid	$12.98
Rate for Payer: UnitedHealthcare Medicare	$10.81
Rate for Payer: University Health Alliance Commercial	$15.77

triamcinolone 0.1% cream 15gm [HHSC]

Facility

$21.63

Service Code	NDC 45802006435
Hospital Charge Code	2500837
Hospital Revenue Code	250
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$20.98
Rate for Payer: Cash Price	$14.06
Rate for Payer: Health Management Network Commercial	$18.39
Rate for Payer: Kaiser Permanente Commercial	$19.47
Rate for Payer: MDX Hawaii PPO	$20.98

Know your out-of-pocket cost for care.

All Charges