Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

90656 VFC - Influenza Trivalent

Professional

Both

$0.01

Service Code	HCPCS 90656
Hospital Charge Code	8050244
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

90656 VFC Influenza Virus Vaccine Trivalent 0.5ml

Professional

Both

$0.01

Service Code	HCPCS 90656
Hospital Charge Code	12259365
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

90661 Flucelvax Trivalent PFS - 0.5ml IM once [<65, egg free, PFS are preservative free]

Facility

$0.01

Service Code	HCPCS 90661
Hospital Charge Code	8581243
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

90661 Flucelvax Trivalent PFS - 0.5ml IM once [<65, egg free, PFS are preservative free]

Facility

$0.01

Service Code	HCPCS 90661
Hospital Charge Code	8581243
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$36.85
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	$36.85
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.85
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

90662 Influenza virus vaccine High Dose, Inactivated PF Trivalent

Professional

Both

$220.00

Service Code	HCPCS 90662
Hospital Charge Code	8041214
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$187.00
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$98.16
Rate for Payer: Cash Price	$143.00
Rate for Payer: Cash Price	$143.00
Rate for Payer: Devoted Health Medicare	$107.98
Rate for Payer: Hawaii Medical Service Association Medicare	$98.16
Rate for Payer: Hawaii Western Management Group Commercial	$53.06
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$117.79
Rate for Payer: Kaiser Permanente Medicaid	$117.79
Rate for Payer: Kaiser Permanente Medicare	$117.79
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicare	$98.16
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$98.16

90670 Pneumococcal 13-valent conjugate vaccine

Professional

Both

$537.00

Service Code	HCPCS 90670
Hospital Charge Code	8041215
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$456.45
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$349.05
Rate for Payer: Cash Price	$349.05
Rate for Payer: Hawaii Western Management Group Commercial	$218.03
Rate for Payer: Health Management Network Commercial	$456.45
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90670 VFC pneumococcal 13-valent conjugate vaccine

Professional

Both

$0.01

Service Code	HCPCS 90670
Hospital Charge Code	8050238
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$218.03
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	$218.03
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

90671 Pneumococcal 15-valent conjugate vaccine

Professional

Both

$535.00

Service Code	HCPCS 90671
Hospital Charge Code	10300703
Hospital Revenue Code	771
Min. Negotiated Rate	$269.31
Max. Negotiated Rate	$454.75
Rate for Payer: AlohaCare Medicare	$269.31
Rate for Payer: Cash Price	$347.75
Rate for Payer: Cash Price	$347.75
Rate for Payer: Devoted Health Medicare	$296.24
Rate for Payer: Hawaii Medical Service Association Medicare	$269.31
Rate for Payer: Health Management Network Commercial	$454.75
Rate for Payer: Kaiser Permanente Commercial	$323.17
Rate for Payer: Kaiser Permanente Medicaid	$323.17
Rate for Payer: Kaiser Permanente Medicare	$323.17
Rate for Payer: Ohana Health Plan Medicare	$269.31
Rate for Payer: UnitedHealthcare Medicare	$269.31

90671 Pneumococcal 15-valent conjugate vaccine

Facility

$408.00

Service Code	HCPCS 90671
Hospital Charge Code	10300703
Hospital Revenue Code	771
Min. Negotiated Rate	$195.86
Max. Negotiated Rate	$395.76
Rate for Payer: AlohaCare Medicaid	$204.00
Rate for Payer: AlohaCare Medicare	$204.00
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cash Price	$265.20
Rate for Payer: Devoted Health Medicare	$224.40
Rate for Payer: Hawaii Medical Service Association ABD	$253.56
Rate for Payer: Hawaii Medical Service Association Medicare	$204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$253.56
Rate for Payer: Hawaii Western Management Group Commercial	$387.60
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Humana Medicare	$204.00
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: Kaiser Permanente Medicaid	$208.08
Rate for Payer: Kaiser Permanente Medicare	$204.00
Rate for Payer: MDX Hawaii PPO	$395.76
Rate for Payer: Ohana Health Plan Medicaid	$204.00
Rate for Payer: Ohana Health Plan Medicare	$204.00
Rate for Payer: UnitedHealthcare Medicaid	$195.86
Rate for Payer: UnitedHealthcare Medicare	$204.00
Rate for Payer: University Health Alliance Commercial	$228.48

90671 Pneumococcal 15-valent conjugate vaccine

Facility

$408.00

Service Code	HCPCS 90671
Hospital Charge Code	10300703
Hospital Revenue Code	771
Min. Negotiated Rate	$346.80
Max. Negotiated Rate	$395.76
Rate for Payer: Cash Price	$265.20
Rate for Payer: Health Management Network Commercial	$346.80
Rate for Payer: Kaiser Permanente Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$395.76

90671 VFC pneumococcal 15-valent conjugate vaccine

Professional

Both

$0.01

Service Code	HCPCS 90671
Hospital Charge Code	10937964
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$323.17
Rate for Payer: AlohaCare Medicare	$269.31
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$296.24
Rate for Payer: Hawaii Medical Service Association Medicare	$269.31
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$323.17
Rate for Payer: Kaiser Permanente Medicaid	$323.17
Rate for Payer: Kaiser Permanente Medicare	$323.17
Rate for Payer: Ohana Health Plan Medicare	$269.31
Rate for Payer: UnitedHealthcare Medicare	$269.31

90671 VFC Pneumococcal 15-valent conjugate vaccine intramuscular suspension

Professional

Both

$0.01

Service Code	HCPCS 90671
Hospital Charge Code	11043295
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$323.17
Rate for Payer: AlohaCare Medicare	$269.31
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$296.24
Rate for Payer: Hawaii Medical Service Association Medicare	$269.31
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$323.17
Rate for Payer: Kaiser Permanente Medicaid	$323.17
Rate for Payer: Kaiser Permanente Medicare	$323.17
Rate for Payer: Ohana Health Plan Medicare	$269.31
Rate for Payer: UnitedHealthcare Medicare	$269.31

90672 VFC FluMist

Professional

Both

$0.01

Service Code	HCPCS 90672
Hospital Charge Code	9690453
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$25.46
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	$25.46
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

90672 VFC Influenza virus vaccine, quadrivalent, live, for intranasal use

Professional

Both

$0.01

Service Code	HCPCS 90672
Hospital Charge Code	8050240
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$25.46
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	$25.46
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

90673 FluBlok

Facility

$104.00

Service Code	HCPCS 90673
Hospital Charge Code	12411340
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

90673 FluBlok

Facility

$104.00

Service Code	HCPCS 90673
Hospital Charge Code	12411340
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

90674 FLUCELVAX QUADRIVALENT(PREFILLED SYRINGE)

Facility

$128.00

Service Code	HCPCS 90674
Hospital Charge Code	8750329
Hospital Revenue Code	636
Min. Negotiated Rate	$34.17
Max. Negotiated Rate	$124.16
Rate for Payer: AlohaCare Medicaid	$64.00
Rate for Payer: AlohaCare Medicare	$64.00
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$70.40
Rate for Payer: Hawaii Medical Service Association ABD	$34.17
Rate for Payer: Hawaii Medical Service Association Medicare	$64.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.17
Rate for Payer: Hawaii Western Management Group Commercial	$121.60
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Humana Medicare	$64.00
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: Kaiser Permanente Medicare	$64.00
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: Ohana Health Plan Medicaid	$64.00
Rate for Payer: Ohana Health Plan Medicare	$64.00
Rate for Payer: UnitedHealthcare Medicaid	$76.80
Rate for Payer: UnitedHealthcare Medicare	$64.00
Rate for Payer: University Health Alliance Commercial	$71.68

90674 FLUCELVAX QUADRIVALENT(PREFILLED SYRINGE)

Facility

$128.00

Service Code	HCPCS 90674
Hospital Charge Code	8750329
Hospital Revenue Code	636
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: MDX Hawaii PPO	$124.16

90677 Pneumococcal 20-Valent (Prevnar 20)

Professional

Both

$449.00

Service Code	HCPCS 90677
Hospital Charge Code	10093833
Hospital Revenue Code	636
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$381.65
Rate for Payer: AlohaCare Medicare	$312.90
Rate for Payer: Cash Price	$291.85
Rate for Payer: Cash Price	$291.85
Rate for Payer: Devoted Health Medicare	$344.19
Rate for Payer: Hawaii Medical Service Association Medicare	$312.90
Rate for Payer: Health Management Network Commercial	$381.65
Rate for Payer: Kaiser Permanente Commercial	$375.48
Rate for Payer: Kaiser Permanente Medicaid	$375.48
Rate for Payer: Kaiser Permanente Medicare	$375.48
Rate for Payer: Ohana Health Plan Medicare	$312.90
Rate for Payer: UnitedHealthcare Medicare	$312.90

90677-Pneumococcal 20-Valent (Prevnar 20)

Facility

$476.00

Service Code	HCPCS 90677
Hospital Charge Code	12124742
Hospital Revenue Code	636
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$461.72
Rate for Payer: AlohaCare Medicaid	$238.00
Rate for Payer: AlohaCare Medicare	$238.00
Rate for Payer: Cash Price	$309.40
Rate for Payer: Cash Price	$309.40
Rate for Payer: Devoted Health Medicare	$261.80
Rate for Payer: Hawaii Medical Service Association ABD	$298.04
Rate for Payer: Hawaii Medical Service Association Medicare	$238.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$298.04
Rate for Payer: Hawaii Western Management Group Commercial	$452.20
Rate for Payer: Health Management Network Commercial	$404.60
Rate for Payer: Humana Medicare	$238.00
Rate for Payer: Kaiser Permanente Commercial	$428.40
Rate for Payer: Kaiser Permanente Medicaid	$242.76
Rate for Payer: Kaiser Permanente Medicare	$238.00
Rate for Payer: MDX Hawaii PPO	$461.72
Rate for Payer: Ohana Health Plan Medicaid	$238.00
Rate for Payer: Ohana Health Plan Medicare	$238.00
Rate for Payer: UnitedHealthcare Medicaid	$285.60
Rate for Payer: UnitedHealthcare Medicare	$238.00
Rate for Payer: University Health Alliance Commercial	$266.56

90677-Pneumococcal 20-Valent (Prevnar 20)

Facility

$476.00

Service Code	HCPCS 90677
Hospital Charge Code	12124742
Hospital Revenue Code	636
Min. Negotiated Rate	$404.60
Max. Negotiated Rate	$461.72
Rate for Payer: Cash Price	$309.40
Rate for Payer: Health Management Network Commercial	$404.60
Rate for Payer: Kaiser Permanente Commercial	$428.40
Rate for Payer: MDX Hawaii PPO	$461.72

90677 VFC Pneumococcal 20-Valent (Prevnar 20)

Professional

Both

$0.01

Service Code	HCPCS 90677
Hospital Charge Code	11501591
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$375.48
Rate for Payer: AlohaCare Medicare	$312.90
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$344.19
Rate for Payer: Hawaii Medical Service Association Medicare	$312.90
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$375.48
Rate for Payer: Kaiser Permanente Medicaid	$375.48
Rate for Payer: Kaiser Permanente Medicare	$375.48
Rate for Payer: Ohana Health Plan Medicare	$312.90
Rate for Payer: UnitedHealthcare Medicare	$312.90

90678 0.5 mL RSV vaccine, preF A-preF B - Admin Immunization Charge

Professional

Both

$893.00

Service Code	HCPCS 90678
Hospital Charge Code	13449800
Hospital Revenue Code	636
Min. Negotiated Rate	$759.05
Max. Negotiated Rate	$759.05
Rate for Payer: Cash Price	$580.45
Rate for Payer: Health Management Network Commercial	$759.05

90678 Respiratory Syncytial Virus (RSV) vaccine pref, bivalent, IM (ABRYSVO)

Professional

Both

$0.01

Service Code	HCPCS 90678
Hospital Charge Code	11640882
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

90679 Abrysvo Adult RSV Vaccine

Facility

$390.00

Hospital Charge Code	11263089
Hospital Revenue Code	636
Min. Negotiated Rate	$331.50
Max. Negotiated Rate	$378.30
Rate for Payer: Cash Price	$253.50
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: MDX Hawaii PPO	$378.30

Know your out-of-pocket cost for care.

All Charges