Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

90461: Pediatric Each Additional - Admin Immunization Charge

Professional

Both

$35.00

Service Code	HCPCS 90461
Hospital Charge Code	9539771
Hospital Revenue Code	771
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$29.75
Rate for Payer: AlohaCare Medicare	$8.86
Rate for Payer: Cash Price	$22.75
Rate for Payer: Cash Price	$22.75
Rate for Payer: Devoted Health Medicare	$9.75
Rate for Payer: Hawaii Medical Service Association Medicare	$8.86
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$10.63
Rate for Payer: Kaiser Permanente Medicaid	$10.63
Rate for Payer: Kaiser Permanente Medicare	$10.63
Rate for Payer: Ohana Health Plan Medicare	$8.86
Rate for Payer: UnitedHealthcare Medicare	$8.86

90470 H1N1 immunization administration (intramuscular, intranasal), including counseling when perfor

Professional

Both

$49.00

Service Code	HCPCS 90470
Hospital Charge Code	8099506
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$41.65
Rate for Payer: Cash Price	$31.85
Rate for Payer: Cash Price	$31.85
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$41.65

90471 ADM VACCINE SINGLE CHARGE.

Facility

$185.00

Service Code	HCPCS 90471
Hospital Charge Code	8242919
Hospital Revenue Code	771
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: MDX Hawaii PPO	$179.45

90471 ADM VACCINE SINGLE CHARGE.

Facility

$185.00

Service Code	HCPCS 90471
Hospital Charge Code	8242919
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$92.50
Rate for Payer: AlohaCare Medicare	$92.50
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$101.75
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$92.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$175.75
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$92.50
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$92.50
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$92.50
Rate for Payer: Ohana Health Plan Medicare	$92.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$92.50
Rate for Payer: University Health Alliance Commercial	$103.60

90471 IM ADM PRQ ID SUBQ IM NJXS 1 VACCINE TechFee

Facility

$179.00

Service Code	HCPCS 90471
Hospital Charge Code	8023461
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$89.50
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$98.45
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$89.50
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$89.50
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$89.50
Rate for Payer: Ohana Health Plan Medicare	$89.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$100.24

90471 IM ADM PRQ ID SUBQ IM NJXS 1 VACCINE TechFee

Facility

$179.00

Service Code	HCPCS 90471
Hospital Charge Code	8023461
Hospital Revenue Code	771
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

90471 Immunization administration: first vaccine

Professional

Both

$100.00

Service Code	HCPCS 90471
Hospital Charge Code	10869894
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

90471 Immunization administration: first vaccine

Facility

$185.00

Service Code	HCPCS 90471
Hospital Charge Code	8041199
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$179.45
Rate for Payer: AlohaCare Medicaid	$92.50
Rate for Payer: AlohaCare Medicare	$92.50
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$101.75
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$92.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$175.75
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Humana Medicare	$92.50
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: Kaiser Permanente Medicaid	$94.35
Rate for Payer: Kaiser Permanente Medicare	$92.50
Rate for Payer: MDX Hawaii PPO	$179.45
Rate for Payer: Ohana Health Plan Medicaid	$92.50
Rate for Payer: Ohana Health Plan Medicare	$92.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$92.50
Rate for Payer: University Health Alliance Commercial	$103.60

90471 Immunization administration: first vaccine

Facility

$185.00

Service Code	HCPCS 90471
Hospital Charge Code	8041199
Hospital Revenue Code	771
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$179.45
Rate for Payer: Cash Price	$120.25
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$166.50
Rate for Payer: MDX Hawaii PPO	$179.45

90471 Immunization administration: first vaccine

Professional

Both

$91.00

Service Code	HCPCS 90471
Hospital Charge Code	8041199
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$77.35
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

90471 PH Immunization administration; first vaccine

Professional

Both

$100.00

Service Code	HCPCS 90471
Hospital Charge Code	8050261
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

90471-Vaccine Administration

Facility

$101.00

Service Code	HCPCS 90471
Hospital Charge Code	8079990
Hospital Revenue Code	450
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

90471-Vaccine Administration

Facility

$101.00

Service Code	HCPCS 90471
Hospital Charge Code	8079990
Hospital Revenue Code	450
Min. Negotiated Rate	$50.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.95
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$73.62

90471 VFC First Dose - Admin Immunization Charge

Professional

Both

$23.11

Service Code	HCPCS 90471
Hospital Charge Code	13245367
Hospital Revenue Code	636
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$28.92
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$15.02
Rate for Payer: Cash Price	$15.02
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$19.64
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

90471 VFC Immunization administration; first vaccine charge

Professional

Both

$100.00

Service Code	HCPCS 90471
Hospital Charge Code	10119384
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

90472 Immunization administration; each additional vaccine

Professional

Both

$45.00

Service Code	HCPCS 90472
Hospital Charge Code	8041200
Hospital Revenue Code	771
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$38.25
Rate for Payer: AlohaCare Medicare	$17.36
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$19.10
Rate for Payer: Hawaii Medical Service Association Medicare	$17.36
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$20.83
Rate for Payer: Kaiser Permanente Medicaid	$20.83
Rate for Payer: Kaiser Permanente Medicare	$20.83
Rate for Payer: Ohana Health Plan Medicare	$17.36
Rate for Payer: UnitedHealthcare Medicare	$17.36

90472 IMMUNIZATION ADMIN VAC EA ADDITIONAL CHARGE

Facility

$120.00

Service Code	HCPCS 90472
Hospital Charge Code	8170176
Hospital Revenue Code	771
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

90472 IMMUNIZATION ADMIN VAC EA ADDITIONAL CHARGE

Facility

$120.00

Service Code	HCPCS 90472
Hospital Charge Code	8170176
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$60.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$66.00
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Medicare	$60.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.28
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$60.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$60.00
Rate for Payer: Ohana Health Plan Medicare	$60.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$67.20

90472-Vaccine Administration Each Addl

Facility

$120.00

Service Code	HCPCS 90472
Hospital Charge Code	8079991
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$60.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$66.00
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Medicare	$60.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.28
Rate for Payer: Hawaii Western Management Group Commercial	$114.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$60.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$60.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$60.00
Rate for Payer: Ohana Health Plan Medicare	$60.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$60.00
Rate for Payer: University Health Alliance Commercial	$67.20

90472-Vaccine Administration Each Addl

Facility

$120.00

Service Code	HCPCS 90472
Hospital Charge Code	8079991
Hospital Revenue Code	771
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$78.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

90472 VFC Each Additional - Admin Immunization Charge

Professional

Both

$45.00

Service Code	HCPCS 90472
Hospital Charge Code	13032580
Hospital Revenue Code	771
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$38.25
Rate for Payer: AlohaCare Medicare	$17.36
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$19.10
Rate for Payer: Hawaii Medical Service Association Medicare	$17.36
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$20.83
Rate for Payer: Kaiser Permanente Medicaid	$20.83
Rate for Payer: Kaiser Permanente Medicare	$20.83
Rate for Payer: Ohana Health Plan Medicare	$17.36
Rate for Payer: UnitedHealthcare Medicare	$17.36

90473 Immunization administration by intranasal or oral route; first vaccine

Professional

Both

$100.00

Service Code	HCPCS 90473
Hospital Charge Code	8041201
Hospital Revenue Code	771
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicare	$18.78
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$20.66
Rate for Payer: Hawaii Medical Service Association Medicare	$18.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.00
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$22.54
Rate for Payer: Kaiser Permanente Medicaid	$22.54
Rate for Payer: Kaiser Permanente Medicare	$22.54
Rate for Payer: Ohana Health Plan Medicare	$18.78
Rate for Payer: UnitedHealthcare Medicare	$18.78

90474 Immunization administration by intranasal or oral route; each additional vaccine

Professional

Both

$56.00

Service Code	HCPCS 90474
Hospital Charge Code	8041202
Hospital Revenue Code	771
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$47.60
Rate for Payer: AlohaCare Medicare	$13.18
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$14.50
Rate for Payer: Hawaii Medical Service Association Medicare	$13.18
Rate for Payer: Hawaii Western Management Group Commercial	$11.00
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$15.82
Rate for Payer: Kaiser Permanente Medicaid	$15.82
Rate for Payer: Kaiser Permanente Medicare	$15.82
Rate for Payer: Ohana Health Plan Medicare	$13.18
Rate for Payer: UnitedHealthcare Medicare	$13.18

90480 Covid-19 Vaccine Adminsitration

Professional

Both

$160.00

Service Code	HCPCS 90480
Hospital Charge Code	11447245
Hospital Revenue Code	771
Min. Negotiated Rate	$136.00
Max. Negotiated Rate	$136.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Health Management Network Commercial	$136.00

90480 COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	11638728
Hospital Revenue Code	771
Min. Negotiated Rate	$72.25
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$55.25
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: MDX Hawaii PPO	$82.45

Know your out-of-pocket cost for care.

All Charges