Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

90480 COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	11638728
Hospital Revenue Code	771
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$82.45
Rate for Payer: AlohaCare Medicaid	$42.50
Rate for Payer: AlohaCare Medicare	$42.50
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$46.75
Rate for Payer: Hawaii Medical Service Association ABD	$47.20
Rate for Payer: Hawaii Medical Service Association Commercial	$51.90
Rate for Payer: Hawaii Medical Service Association Medicare	$42.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.20
Rate for Payer: Hawaii Western Management Group Commercial	$80.75
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Humana Medicare	$42.50
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: Kaiser Permanente Medicare	$42.50
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: Ohana Health Plan Medicaid	$42.50
Rate for Payer: Ohana Health Plan Medicare	$42.50
Rate for Payer: UnitedHealthcare Medicaid	$31.14
Rate for Payer: UnitedHealthcare Medicare	$42.50
Rate for Payer: University Health Alliance Commercial	$47.60

90480-COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	12108792
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

90480-COVID Vaccine Admin charge

Facility

$85.00

Service Code	HCPCS 90480
Hospital Charge Code	12108792
Hospital Revenue Code	771
Min. Negotiated Rate	$31.14
Max. Negotiated Rate	$82.45
Rate for Payer: AlohaCare Medicaid	$42.50
Rate for Payer: AlohaCare Medicare	$42.50
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$46.75
Rate for Payer: Hawaii Medical Service Association ABD	$47.20
Rate for Payer: Hawaii Medical Service Association Commercial	$51.90
Rate for Payer: Hawaii Medical Service Association Medicare	$42.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.20
Rate for Payer: Hawaii Western Management Group Commercial	$80.75
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Humana Medicare	$42.50
Rate for Payer: Kaiser Permanente Commercial	$76.50
Rate for Payer: Kaiser Permanente Medicaid	$43.35
Rate for Payer: Kaiser Permanente Medicare	$42.50
Rate for Payer: MDX Hawaii PPO	$82.45
Rate for Payer: Ohana Health Plan Medicaid	$42.50
Rate for Payer: Ohana Health Plan Medicare	$42.50
Rate for Payer: UnitedHealthcare Medicaid	$31.14
Rate for Payer: UnitedHealthcare Medicare	$42.50
Rate for Payer: University Health Alliance Commercial	$47.60

90619 Meningococcal (MenQuadfi) conjugate vaccine, quadrivalent, for intramuscular use HHSC

Professional

Both

$385.00

Service Code	HCPCS 90619
Hospital Charge Code	10399140
Hospital Revenue Code	636
Min. Negotiated Rate	$327.25
Max. Negotiated Rate	$327.25
Rate for Payer: Cash Price	$250.25
Rate for Payer: Health Management Network Commercial	$327.25

90619 MenQuadfi

Professional

Both

$385.00

Service Code	HCPCS 90619
Hospital Charge Code	10231070
Hospital Revenue Code	636
Min. Negotiated Rate	$327.25
Max. Negotiated Rate	$327.25
Rate for Payer: Cash Price	$250.25
Rate for Payer: Health Management Network Commercial	$327.25

90619 VFC Meningococcal (MenQuadfi) conjugate vaccine, quadrivalent, for intramuscular use HHSC

Professional

Both

$0.01

Service Code	HCPCS 90619
Hospital Charge Code	10397033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

90619 VFC MenQuadfi

Professional

Both

$0.01

Service Code	HCPCS 90619
Hospital Charge Code	10232669
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01

90620 Meningococcal vaccine, Serogroup B, 2 dose schedule, for IM use

Professional

Both

$468.00

Service Code	HCPCS 90620
Hospital Charge Code	8041204
Hospital Revenue Code	771
Min. Negotiated Rate	$193.50
Max. Negotiated Rate	$397.80
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cash Price	$304.20
Rate for Payer: Hawaii Western Management Group Commercial	$193.50
Rate for Payer: Health Management Network Commercial	$397.80

90620 VFC MENB RECOMBINANT

Professional

Both

$0.01

Service Code	HCPCS 90620
Hospital Charge Code	9003826
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$193.50
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$193.50
Rate for Payer: Health Management Network Commercial	$0.01

90632 Hepatitis A vaccine, adult dosage, for intramuscular use

Professional

Both

$193.00

Service Code	HCPCS 90632
Hospital Charge Code	8041205
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$164.05
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$73.73
Rate for Payer: Cash Price	$125.45
Rate for Payer: Cash Price	$125.45
Rate for Payer: Devoted Health Medicare	$81.10
Rate for Payer: Hawaii Medical Service Association Medicare	$73.73
Rate for Payer: Hawaii Western Management Group Commercial	$69.21
Rate for Payer: Health Management Network Commercial	$164.05
Rate for Payer: Kaiser Permanente Commercial	$88.48
Rate for Payer: Kaiser Permanente Medicaid	$88.48
Rate for Payer: Kaiser Permanente Medicare	$88.48
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$73.73
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$73.73

90633 Havrix Hepatitis A vaccine, 2 dose schedule, for intramuscular use

Professional

Both

$94.00

Service Code	HCPCS 90633
Hospital Charge Code	8050284
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$79.90
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$61.10
Rate for Payer: Cash Price	$61.10
Rate for Payer: Hawaii Western Management Group Commercial	$36.02
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90633 PH Havrix Hepatitis A vaccine, 2 dose schedule, for intramuscular use

Professional

Both

$0.01

Service Code	HCPCS 90633
Hospital Charge Code	8041206
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.02
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$36.02
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90634 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular u

Professional

Both

$183.00

Service Code	HCPCS 90634
Hospital Charge Code	8149537
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$155.55
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$118.95
Rate for Payer: Cash Price	$118.95
Rate for Payer: Hawaii Western Management Group Commercial	$60.00
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90634 VFC Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular

Professional

Both

$0.01

Service Code	HCPCS 90634
Hospital Charge Code	8180326
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$60.00
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$60.00
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90648 Hib PRP-T Conjugate VFC 4 dose schedule IM

Professional

Both

$69.00

Service Code	HCPCS 90648
Hospital Charge Code	8046241
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$58.65
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Hawaii Western Management Group Commercial	$29.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90648 PH Hib PRP-T Conjugate 4 dose schedule IM

Professional

Both

$0.01

Service Code	HCPCS 90648
Hospital Charge Code	8050236
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$29.55
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$29.55
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90651 PH Vaccine- Gardasil 9

Professional

Both

$0.01

Service Code	HCPCS 90651
Hospital Charge Code	8050237
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$234.35
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$234.35
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90651 Vaccine- Gardasil 9 VFC

Professional

Both

$551.00

Service Code	HCPCS 90651
Hospital Charge Code	8041210
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$468.35
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$358.15
Rate for Payer: Cash Price	$358.15
Rate for Payer: Hawaii Western Management Group Commercial	$234.35
Rate for Payer: Health Management Network Commercial	$468.35
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90653 High dose influenza virus vaccine (2025-2026 Fluad 0.5mL, 65 yrs & older)

Facility

$104.00

Service Code	HCPCS 90653
Hospital Charge Code	13245282
Hospital Revenue Code	771
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$67.60
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: MDX Hawaii PPO	$100.88

90653 High dose influenza virus vaccine (2025-2026 Fluad 0.5mL, 65 yrs & older)

Facility

$104.00

Service Code	HCPCS 90653
Hospital Charge Code	13245282
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$52.00
Rate for Payer: AlohaCare Medicare	$52.00
Rate for Payer: Cash Price	$67.60
Rate for Payer: Cash Price	$67.60
Rate for Payer: Devoted Health Medicare	$57.20
Rate for Payer: Hawaii Medical Service Association ABD	$83.49
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$83.49
Rate for Payer: Hawaii Western Management Group Commercial	$98.80
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$52.00
Rate for Payer: Kaiser Permanente Commercial	$93.60
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$52.00
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$52.00
Rate for Payer: Ohana Health Plan Medicare	$52.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$58.24

90653 Influenza vaccine, inactivated (Fluad) High Dose for intramuscular use

Facility

$0.01

Service Code	HCPCS 90653
Hospital Charge Code	12273679
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01

90653 Influenza vaccine, inactivated (Fluad) High Dose for intramuscular use

Facility

$0.01

Service Code	HCPCS 90653
Hospital Charge Code	12273679
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$83.49
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association ABD	$83.49
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$83.49
Rate for Payer: Hawaii Western Management Group Commercial	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: Kaiser Permanente Medicaid	$0.01
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.01

90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use (Fluad)

Professional

Both

$97.00

Service Code	HCPCS 90686
Hospital Charge Code	8041220
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$82.45
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Hawaii Western Management Group Commercial	$22.01
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90656 Influenza virus vaccine, trivalent, split virus fluarix

Professional

Both

$72.00

Service Code	HCPCS 90656
Hospital Charge Code	8041212
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$61.20
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$23.22
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Devoted Health Medicare	$25.54
Rate for Payer: Hawaii Medical Service Association Medicare	$23.22
Rate for Payer: Hawaii Western Management Group Commercial	$18.73
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$27.86
Rate for Payer: Kaiser Permanente Medicaid	$27.86
Rate for Payer: Kaiser Permanente Medicare	$27.86
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$23.22
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$23.22

90656 VFC Fluzone 6 months and Older

Professional

Both

$0.01

Service Code	HCPCS 90656
Hospital Charge Code	12305378
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$27.86
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$23.22
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$25.54
Rate for Payer: Hawaii Medical Service Association Medicare	$23.22
Rate for Payer: Hawaii Western Management Group Commercial	$18.73
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$27.86
Rate for Payer: Kaiser Permanente Medicaid	$27.86
Rate for Payer: Kaiser Permanente Medicare	$27.86
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$23.22
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$23.22

Know your out-of-pocket cost for care.

All Charges