Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

90679 Abrysvo Adult RSV Vaccine

Facility

$390.00

Hospital Charge Code	11263089
Hospital Revenue Code	636
Min. Negotiated Rate	$195.00
Max. Negotiated Rate	$378.30
Rate for Payer: AlohaCare Medicaid	$195.00
Rate for Payer: AlohaCare Medicare	$195.00
Rate for Payer: Cash Price	$253.50
Rate for Payer: Devoted Health Medicare	$214.50
Rate for Payer: Hawaii Medical Service Association Medicare	$195.00
Rate for Payer: Hawaii Western Management Group Commercial	$370.50
Rate for Payer: Health Management Network Commercial	$331.50
Rate for Payer: Humana Medicare	$195.00
Rate for Payer: Kaiser Permanente Commercial	$351.00
Rate for Payer: Kaiser Permanente Medicaid	$198.90
Rate for Payer: Kaiser Permanente Medicare	$195.00
Rate for Payer: MDX Hawaii PPO	$378.30
Rate for Payer: Ohana Health Plan Medicaid	$195.00
Rate for Payer: Ohana Health Plan Medicare	$195.00
Rate for Payer: UnitedHealthcare Medicaid	$234.00
Rate for Payer: UnitedHealthcare Medicare	$195.00
Rate for Payer: University Health Alliance Commercial	$218.40

90680 PH Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use

Professional

Both

$0.01

Service Code	HCPCS 90680
Hospital Charge Code	8050242
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$89.39
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	$89.39
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

90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use

Professional

Both

$246.00

Service Code	HCPCS 90680
Hospital Charge Code	8041218
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$209.10
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Hawaii Western Management Group Commercial	$89.39
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90685 Influenza virus vaccine, quadrivalent, split virus, pre free, 6-35 mo, for intramuscular use

Professional

Both

$79.00

Service Code	HCPCS 90685
Hospital Charge Code	8041219
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$67.15
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$51.35
Rate for Payer: Cash Price	$51.35
Rate for Payer: Hawaii Western Management Group Commercial	$23.30
Rate for Payer: Health Management Network Commercial	$67.15
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90685 PH Influenza virus vaccine, quadrivalent

Professional

Both

$0.01

Service Code	HCPCS 90685
Hospital Charge Code	8665176
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$23.30
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	$23.30
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

90686 Influenza HD (PF) Prefill

Professional

Both

$150.00

Service Code	HCPCS 90686
Hospital Charge Code	10393167
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$127.50
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Hawaii Western Management Group Commercial	$22.01
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90686 Influenza Preservative Free Quadrivalent

Professional

Both

$119.00

Service Code	HCPCS 90686
Hospital Charge Code	10387173
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$101.15
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$77.35
Rate for Payer: Cash Price	$77.35
Rate for Payer: Hawaii Western Management Group Commercial	$22.01
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90686 Influenza Quadrivalent

Professional

Both

$100.00

Service Code	HCPCS 90686
Hospital Charge Code	10387658
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.01
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90686 VFC - Influenza Preservative Free Quadrivalent

Professional

Both

$0.01

Service Code	HCPCS 90686
Hospital Charge Code	10393212
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$22.01
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	$22.01
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

90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage

Professional

Both

$172.00

Service Code	HCPCS 90688
Hospital Charge Code	8041221
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$146.20
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$111.80
Rate for Payer: Cash Price	$111.80
Rate for Payer: Hawaii Western Management Group Commercial	$18.16
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90688 VFC Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage

Professional

Both

$0.01

Service Code	HCPCS 90688
Hospital Charge Code	8050245
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$18.16
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	$18.16
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

90696 DTaP-IPV, when administered to children 4 through 6 years of age, for intramuscular use

Professional

Both

$199.00

Service Code	HCPCS 90696
Hospital Charge Code	8041223
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$169.15
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Hawaii Western Management Group Commercial	$64.12
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90696 PH DTaP-IPV, when administered to children 4 through 6 years of age, for intramuscular use

Professional

Both

$0.01

Service Code	HCPCS 90696
Hospital Charge Code	8050246
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$64.12
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	$64.12
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

90697 DTaP/IPV/HIB/HepB (Vaxelis), for intramuscular use

Professional

Both

$379.00

Service Code	HCPCS 90697
Hospital Charge Code	11165047
Hospital Revenue Code	771
Min. Negotiated Rate	$322.15
Max. Negotiated Rate	$322.15
Rate for Payer: Cash Price	$246.35
Rate for Payer: Health Management Network Commercial	$322.15

90697 DTaP-IPV-HibHepB (Vaxelis) Vaccine

Professional

Both

$379.00

Service Code	HCPCS 90697
Hospital Charge Code	10510186
Hospital Revenue Code	636
Min. Negotiated Rate	$322.15
Max. Negotiated Rate	$322.15
Rate for Payer: Cash Price	$246.35
Rate for Payer: Health Management Network Commercial	$322.15

90697 VFC - Vaxelis DTaP-IPV-Hib-HepB

Professional

Both

$0.01

Service Code	HCPCS 90697
Hospital Charge Code	9818973
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

90698 DTaP - Hib - IPV, for intramuscular use

Professional

Both

$339.00

Service Code	HCPCS 90698
Hospital Charge Code	8041224
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$288.15
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$220.35
Rate for Payer: Cash Price	$220.35
Rate for Payer: Hawaii Western Management Group Commercial	$89.50
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90698 PH DTaP - Hib - IPV (Pentacel), for intramuscular use

Professional

Both

$0.01

Service Code	HCPCS 90698
Hospital Charge Code	8050247
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$89.50
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	$89.50
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

90700 DAPTACEL DTaP, under 7 years, for IM use

Professional

Both

$98.00

Service Code	HCPCS 90700
Hospital Charge Code	8041225
Hospital Revenue Code	636
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$83.30
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$63.70
Rate for Payer: Cash Price	$63.70
Rate for Payer: Hawaii Western Management Group Commercial	$31.13
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90700 VFC DAPTACEL DTaP, under 7 years, for IM use

Professional

Both

$0.01

Service Code	HCPCS 90700
Hospital Charge Code	8050248
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$31.13
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	$31.13
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

90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

Professional

Both

$134.00

Service Code	HCPCS 90707
Hospital Charge Code	8041227
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$113.90
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Cash Price	$87.10
Rate for Payer: Hawaii Western Management Group Commercial	$80.64
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90707 PH Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

Professional

Both

$0.01

Service Code	HCPCS 90707
Hospital Charge Code	8050250
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$80.64
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	$80.64
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

90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

Professional

Both

$384.00

Service Code	HCPCS 90710
Hospital Charge Code	8041228
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$326.40
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: Cash Price	$249.60
Rate for Payer: Cash Price	$249.60
Rate for Payer: Hawaii Western Management Group Commercial	$230.98
Rate for Payer: Health Management Network Commercial	$326.40
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00

90710 PH Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

Professional

Both

$0.01

Service Code	HCPCS 90710
Hospital Charge Code	8050251
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$230.98
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	$230.98
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

90713 PH Poliovirus vaccine, inactivated (IPV)

Professional

Both

$0.01

Service Code	HCPCS 90713
Hospital Charge Code	8050252
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$33.41
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	$33.41
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

Know your out-of-pocket cost for care.

All Charges