Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$86.41

Service Code	NDC 24208073501
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$73.45
Max. Negotiated Rate	$83.82
Rate for Payer: Cash Price	$56.17
Rate for Payer: Health Management Network Commercial	$73.45
Rate for Payer: Kaiser Permanente Commercial	$77.77
Rate for Payer: MDX Hawaii PPO	$83.82

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$187.40

Service Code	NDC 00065039602
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$93.70
Max. Negotiated Rate	$181.78
Rate for Payer: AlohaCare Medicaid	$93.70
Rate for Payer: AlohaCare Medicare	$93.70
Rate for Payer: Cash Price	$121.81
Rate for Payer: Devoted Health Medicare	$103.07
Rate for Payer: Hawaii Medical Service Association Medicare	$93.70
Rate for Payer: Hawaii Western Management Group Commercial	$178.03
Rate for Payer: Health Management Network Commercial	$159.29
Rate for Payer: Humana Medicare	$93.70
Rate for Payer: Kaiser Permanente Commercial	$168.66
Rate for Payer: Kaiser Permanente Medicaid	$95.57
Rate for Payer: Kaiser Permanente Medicare	$93.70
Rate for Payer: MDX Hawaii PPO	$181.78
Rate for Payer: Ohana Health Plan Medicaid	$93.70
Rate for Payer: Ohana Health Plan Medicare	$93.70
Rate for Payer: UnitedHealthcare Medicaid	$112.44
Rate for Payer: UnitedHealthcare Medicare	$93.70
Rate for Payer: University Health Alliance Commercial	$136.60

cyclopentolate 1% ophth drops 2ml [HHSC]

Facility

$88.37

Service Code	NDC 61314039601
Hospital Charge Code	2500213
Hospital Revenue Code	250
Min. Negotiated Rate	$44.19
Max. Negotiated Rate	$85.72
Rate for Payer: AlohaCare Medicaid	$44.19
Rate for Payer: AlohaCare Medicare	$44.19
Rate for Payer: Cash Price	$57.44
Rate for Payer: Devoted Health Medicare	$48.60
Rate for Payer: Hawaii Medical Service Association Medicare	$44.19
Rate for Payer: Hawaii Western Management Group Commercial	$83.95
Rate for Payer: Health Management Network Commercial	$75.11
Rate for Payer: Humana Medicare	$44.19
Rate for Payer: Kaiser Permanente Commercial	$79.53
Rate for Payer: Kaiser Permanente Medicaid	$45.07
Rate for Payer: Kaiser Permanente Medicare	$44.19
Rate for Payer: MDX Hawaii PPO	$85.72
Rate for Payer: Ohana Health Plan Medicaid	$44.19
Rate for Payer: Ohana Health Plan Medicare	$44.19
Rate for Payer: UnitedHealthcare Medicaid	$53.02
Rate for Payer: UnitedHealthcare Medicare	$44.19
Rate for Payer: University Health Alliance Commercial	$64.41

Cyclosporine FSI

Facility

$206.00

Service Code	HCPCS 80158
Hospital Charge Code	8117900
Hospital Revenue Code	301
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$199.82
Rate for Payer: AlohaCare Medicaid	$103.00
Rate for Payer: AlohaCare Medicare	$103.00
Rate for Payer: Cash Price	$133.90
Rate for Payer: Cash Price	$133.90
Rate for Payer: Devoted Health Medicare	$113.30
Rate for Payer: Hawaii Medical Service Association ABD	$24.95
Rate for Payer: Hawaii Medical Service Association Commercial	$22.56
Rate for Payer: Hawaii Medical Service Association Medicare	$103.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.20
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Humana Medicare	$103.00
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: Kaiser Permanente Medicaid	$105.06
Rate for Payer: Kaiser Permanente Medicare	$103.00
Rate for Payer: MDX Hawaii PPO	$199.82
Rate for Payer: Ohana Health Plan Medicaid	$103.00
Rate for Payer: Ohana Health Plan Medicare	$103.00
Rate for Payer: UnitedHealthcare Medicaid	$24.95
Rate for Payer: UnitedHealthcare Medicare	$103.00
Rate for Payer: University Health Alliance Commercial	$46.68

Cyclosporine FSI

Facility

$206.00

Service Code	HCPCS 80158
Hospital Charge Code	8117900
Hospital Revenue Code	301
Min. Negotiated Rate	$175.10
Max. Negotiated Rate	$199.82
Rate for Payer: Cash Price	$133.90
Rate for Payer: Health Management Network Commercial	$175.10
Rate for Payer: Kaiser Permanente Commercial	$185.40
Rate for Payer: MDX Hawaii PPO	$199.82

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$13.01

Service Code	NDC 00264761200
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$8.46
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: MDX Hawaii PPO	$12.62

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$13.01

Service Code	NDC 00264761200
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.62
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.46
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$12.36
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: Kaiser Permanente Medicaid	$6.64
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.62
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicaid	$7.81
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$30.64

Service Code	NDC 00409792609
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$26.04
Max. Negotiated Rate	$29.72
Rate for Payer: Cash Price	$19.92
Rate for Payer: Health Management Network Commercial	$26.04
Rate for Payer: Kaiser Permanente Commercial	$27.58
Rate for Payer: MDX Hawaii PPO	$29.72

D5W-NACL 0.45% 1000ml [HHSC]

Facility

$30.64

Service Code	NDC 00409792609
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$15.32
Max. Negotiated Rate	$29.72
Rate for Payer: AlohaCare Medicaid	$15.32
Rate for Payer: AlohaCare Medicare	$15.32
Rate for Payer: Cash Price	$19.92
Rate for Payer: Devoted Health Medicare	$16.85
Rate for Payer: Hawaii Medical Service Association Medicare	$15.32
Rate for Payer: Hawaii Western Management Group Commercial	$29.11
Rate for Payer: Health Management Network Commercial	$26.04
Rate for Payer: Humana Medicare	$15.32
Rate for Payer: Kaiser Permanente Commercial	$27.58
Rate for Payer: Kaiser Permanente Medicaid	$15.63
Rate for Payer: Kaiser Permanente Medicare	$15.32
Rate for Payer: MDX Hawaii PPO	$29.72
Rate for Payer: Ohana Health Plan Medicaid	$15.32
Rate for Payer: Ohana Health Plan Medicare	$15.32
Rate for Payer: UnitedHealthcare Medicaid	$18.38
Rate for Payer: UnitedHealthcare Medicare	$15.32
Rate for Payer: University Health Alliance Commercial	$22.33

D5W-NACL 0.45%-KCL 20 mEq/L [HHSC]

Facility

$14.96

Service Code	HCPCS J3480
Hospital Charge Code	2500878
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$14.51
Rate for Payer: AlohaCare Medicaid	$7.48
Rate for Payer: AlohaCare Medicare	$7.48
Rate for Payer: Cash Price	$9.72
Rate for Payer: Cash Price	$9.72
Rate for Payer: Devoted Health Medicare	$8.23
Rate for Payer: Hawaii Medical Service Association ABD	$0.17
Rate for Payer: Hawaii Medical Service Association Medicare	$7.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.17
Rate for Payer: Hawaii Western Management Group Commercial	$14.21
Rate for Payer: Health Management Network Commercial	$12.72
Rate for Payer: Humana Medicare	$7.48
Rate for Payer: Kaiser Permanente Commercial	$13.46
Rate for Payer: Kaiser Permanente Medicaid	$7.63
Rate for Payer: Kaiser Permanente Medicare	$7.48
Rate for Payer: MDX Hawaii PPO	$14.51
Rate for Payer: Ohana Health Plan Medicaid	$7.48
Rate for Payer: Ohana Health Plan Medicare	$7.48
Rate for Payer: UnitedHealthcare Medicaid	$8.98
Rate for Payer: UnitedHealthcare Medicare	$7.48
Rate for Payer: University Health Alliance Commercial	$10.90

D5W-NACL 0.45%-KCL 20 mEq/L [HHSC]

Facility

$14.96

Service Code	HCPCS J3480
Hospital Charge Code	2500878
Hospital Revenue Code	250
Min. Negotiated Rate	$12.72
Max. Negotiated Rate	$14.51
Rate for Payer: Cash Price	$9.72
Rate for Payer: Health Management Network Commercial	$12.72
Rate for Payer: Kaiser Permanente Commercial	$13.46
Rate for Payer: MDX Hawaii PPO	$14.51

D5W-NACL 0.9% 1000ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7042
Hospital Charge Code	2500239
Hospital Revenue Code	250
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$8.46
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: MDX Hawaii PPO	$12.62

D5W-NACL 0.9% 1000ml [HHSC]

Facility

$13.01

Service Code	HCPCS J7042
Hospital Charge Code	2500239
Hospital Revenue Code	636
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$12.62
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cash Price	$8.46
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association ABD	$1.36
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.36
Rate for Payer: Hawaii Western Management Group Commercial	$12.36
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: Kaiser Permanente Medicaid	$6.64
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.62
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicaid	$7.81
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL

Facility

$8,656.00

Service Code	HCPCS 11005
Hospital Charge Code	8803193
Hospital Revenue Code	361
Min. Negotiated Rate	$7,357.60
Max. Negotiated Rate	$8,396.32
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Health Management Network Commercial	$7,357.60
Rate for Payer: Kaiser Permanente Commercial	$7,790.40
Rate for Payer: MDX Hawaii PPO	$8,396.32

DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL

Facility

$8,656.00

Service Code	HCPCS 11005
Hospital Charge Code	8803193
Hospital Revenue Code	361
Min. Negotiated Rate	$566.13
Max. Negotiated Rate	$8,396.32
Rate for Payer: AlohaCare Medicaid	$4,328.00
Rate for Payer: AlohaCare Medicare	$4,328.00
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Cash Price	$5,626.40
Rate for Payer: Devoted Health Medicare	$4,760.80
Rate for Payer: Hawaii Medical Service Association Medicare	$4,328.00
Rate for Payer: Health Management Network Commercial	$7,357.60
Rate for Payer: Humana Medicare	$4,328.00
Rate for Payer: Kaiser Permanente Commercial	$7,790.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,328.00
Rate for Payer: MDX Hawaii PPO	$8,396.32
Rate for Payer: Ohana Health Plan Medicaid	$4,328.00
Rate for Payer: Ohana Health Plan Medicare	$4,328.00
Rate for Payer: UnitedHealthcare Medicaid	$566.13
Rate for Payer: UnitedHealthcare Medicare	$4,328.00
Rate for Payer: University Health Alliance Commercial	$4,847.36

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC

Facility

$15,643.32

Service Code	MSDRG 744
Min. Negotiated Rate	$15,643.32
Max. Negotiated Rate	$15,643.32
Rate for Payer: Hawaii Medical Service Association Commercial	$15,643.32

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC

Facility

$15,643.32

Service Code	MSDRG 745
Min. Negotiated Rate	$15,643.32
Max. Negotiated Rate	$15,643.32
Rate for Payer: Hawaii Medical Service Association Commercial	$15,643.32

D-Dimer, Quantitative REF

Facility

$145.00

Service Code	HCPCS 85379
Hospital Charge Code	8160152
Hospital Revenue Code	305
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$72.50
Rate for Payer: AlohaCare Medicare	$72.50
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$79.75
Rate for Payer: Hawaii Medical Service Association ABD	$14.06
Rate for Payer: Hawaii Medical Service Association Commercial	$12.72
Rate for Payer: Hawaii Medical Service Association Medicare	$72.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.76
Rate for Payer: Hawaii Western Management Group Commercial	$10.18
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$72.50
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$72.50
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$72.50
Rate for Payer: Ohana Health Plan Medicare	$72.50
Rate for Payer: UnitedHealthcare Medicaid	$14.06
Rate for Payer: UnitedHealthcare Medicare	$72.50
Rate for Payer: University Health Alliance Commercial	$26.31

D-Dimer, Quantitative REF

Facility

$145.00

Service Code	HCPCS 85379
Hospital Charge Code	8160152
Hospital Revenue Code	305
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$130.50
Rate for Payer: MDX Hawaii PPO	$140.65

Declot PICC, CVC Nursing

Facility

$1,263.00

Service Code	HCPCS 36593
Hospital Charge Code	11934638
Hospital Revenue Code	450
Min. Negotiated Rate	$1,073.55
Max. Negotiated Rate	$1,225.11
Rate for Payer: Cash Price	$820.95
Rate for Payer: Health Management Network Commercial	$1,073.55
Rate for Payer: Kaiser Permanente Commercial	$1,136.70
Rate for Payer: MDX Hawaii PPO	$1,225.11

Declot PICC, CVC Nursing

Facility

$1,263.00

Service Code	HCPCS 36593
Hospital Charge Code	11934638
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$631.50
Rate for Payer: AlohaCare Medicare	$631.50
Rate for Payer: Cash Price	$820.95
Rate for Payer: Cash Price	$820.95
Rate for Payer: Devoted Health Medicare	$694.65
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	$631.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,199.85
Rate for Payer: Health Management Network Commercial	$1,073.55
Rate for Payer: Humana Medicare	$631.50
Rate for Payer: Kaiser Permanente Commercial	$1,136.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$631.50
Rate for Payer: MDX Hawaii PPO	$1,225.11
Rate for Payer: Ohana Health Plan Medicaid	$631.50
Rate for Payer: Ohana Health Plan Medicare	$631.50
Rate for Payer: UnitedHealthcare Medicare	$631.50
Rate for Payer: University Health Alliance Commercial	$920.60

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$25,835.18

Service Code	MSDRG 056
Min. Negotiated Rate	$25,835.18
Max. Negotiated Rate	$25,835.18
Rate for Payer: Hawaii Medical Service Association Commercial	$25,835.18

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$25,835.18

Service Code	MSDRG 057
Min. Negotiated Rate	$25,835.18
Max. Negotiated Rate	$25,835.18
Rate for Payer: Hawaii Medical Service Association Commercial	$25,835.18

DELTA TERRY-NET ADHESIVE BLACK 1.25X15YD 1/RL

Facility

$103.00

Hospital Charge Code	12957403
Hospital Revenue Code	270
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$66.95
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: MDX Hawaii PPO	$99.91

DELTA TERRY-NET ADHESIVE BLACK 1.25X15YD 1/RL

Facility

$103.00

Hospital Charge Code	12957403
Hospital Revenue Code	270
Min. Negotiated Rate	$51.50
Max. Negotiated Rate	$99.91
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$51.50
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$56.65
Rate for Payer: Hawaii Medical Service Association Medicare	$51.50
Rate for Payer: Hawaii Western Management Group Commercial	$97.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$51.50
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$51.50
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$51.50
Rate for Payer: Ohana Health Plan Medicare	$51.50
Rate for Payer: UnitedHealthcare Medicare	$51.50
Rate for Payer: University Health Alliance Commercial	$75.08

Know your out-of-pocket cost for care.

All Charges