Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

diphenhydrAMINE 50 mg/ml vial [HHSC]

Facility

$3.72

Service Code	HCPCS J1200
Hospital Charge Code	2500262
Hospital Revenue Code	250
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$3.61
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cash Price	$4.62
Rate for Payer: Cash Price	$11.93
Rate for Payer: Cash Price	$25.28
Rate for Payer: Health Management Network Commercial	$15.60
Rate for Payer: Health Management Network Commercial	$6.04
Rate for Payer: Health Management Network Commercial	$3.16
Rate for Payer: Health Management Network Commercial	$33.06
Rate for Payer: Kaiser Permanente Commercial	$16.52
Rate for Payer: Kaiser Permanente Commercial	$6.40
Rate for Payer: Kaiser Permanente Commercial	$35.01
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: MDX Hawaii PPO	$6.90
Rate for Payer: MDX Hawaii PPO	$17.80
Rate for Payer: MDX Hawaii PPO	$3.61
Rate for Payer: MDX Hawaii PPO	$37.73

diphenhydrAMINE 50 mg/ml vial [HHSC]

Facility

$3.72

Service Code	HCPCS J1200
Hospital Charge Code	2500262
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$3.61
Rate for Payer: AlohaCare Medicaid	$1.86
Rate for Payer: AlohaCare Medicaid	$19.45
Rate for Payer: AlohaCare Medicaid	$9.18
Rate for Payer: AlohaCare Medicaid	$3.56
Rate for Payer: AlohaCare Medicare	$3.56
Rate for Payer: AlohaCare Medicare	$9.18
Rate for Payer: AlohaCare Medicare	$1.86
Rate for Payer: AlohaCare Medicare	$19.45
Rate for Payer: Cash Price	$4.62
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cash Price	$11.93
Rate for Payer: Cash Price	$4.62
Rate for Payer: Cash Price	$11.93
Rate for Payer: Cash Price	$25.28
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cash Price	$25.28
Rate for Payer: Devoted Health Medicare	$21.39
Rate for Payer: Devoted Health Medicare	$2.05
Rate for Payer: Devoted Health Medicare	$3.91
Rate for Payer: Devoted Health Medicare	$10.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.18
Rate for Payer: Hawaii Medical Service Association Medicare	$3.56
Rate for Payer: Hawaii Medical Service Association Medicare	$19.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$6.75
Rate for Payer: Hawaii Western Management Group Commercial	$36.95
Rate for Payer: Hawaii Western Management Group Commercial	$17.43
Rate for Payer: Hawaii Western Management Group Commercial	$3.53
Rate for Payer: Health Management Network Commercial	$33.06
Rate for Payer: Health Management Network Commercial	$15.60
Rate for Payer: Health Management Network Commercial	$3.16
Rate for Payer: Health Management Network Commercial	$6.04
Rate for Payer: Humana Medicare	$9.18
Rate for Payer: Humana Medicare	$19.45
Rate for Payer: Humana Medicare	$1.86
Rate for Payer: Humana Medicare	$3.56
Rate for Payer: Kaiser Permanente Commercial	$35.01
Rate for Payer: Kaiser Permanente Commercial	$3.35
Rate for Payer: Kaiser Permanente Commercial	$16.52
Rate for Payer: Kaiser Permanente Commercial	$6.40
Rate for Payer: Kaiser Permanente Medicaid	$1.90
Rate for Payer: Kaiser Permanente Medicaid	$19.84
Rate for Payer: Kaiser Permanente Medicaid	$9.36
Rate for Payer: Kaiser Permanente Medicaid	$3.63
Rate for Payer: Kaiser Permanente Medicare	$19.45
Rate for Payer: Kaiser Permanente Medicare	$9.18
Rate for Payer: Kaiser Permanente Medicare	$3.56
Rate for Payer: Kaiser Permanente Medicare	$1.86
Rate for Payer: MDX Hawaii PPO	$37.73
Rate for Payer: MDX Hawaii PPO	$17.80
Rate for Payer: MDX Hawaii PPO	$6.90
Rate for Payer: MDX Hawaii PPO	$3.61
Rate for Payer: Ohana Health Plan Medicaid	$1.86
Rate for Payer: Ohana Health Plan Medicaid	$19.45
Rate for Payer: Ohana Health Plan Medicaid	$9.18
Rate for Payer: Ohana Health Plan Medicaid	$3.56
Rate for Payer: Ohana Health Plan Medicare	$3.56
Rate for Payer: Ohana Health Plan Medicare	$19.45
Rate for Payer: Ohana Health Plan Medicare	$1.86
Rate for Payer: Ohana Health Plan Medicare	$9.18
Rate for Payer: UnitedHealthcare Medicaid	$2.23
Rate for Payer: UnitedHealthcare Medicaid	$23.34
Rate for Payer: UnitedHealthcare Medicaid	$11.01
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: UnitedHealthcare Medicare	$9.18
Rate for Payer: UnitedHealthcare Medicare	$19.45
Rate for Payer: UnitedHealthcare Medicare	$3.56
Rate for Payer: UnitedHealthcare Medicare	$1.86
Rate for Payer: University Health Alliance Commercial	$13.38
Rate for Payer: University Health Alliance Commercial	$2.71
Rate for Payer: University Health Alliance Commercial	$28.35
Rate for Payer: University Health Alliance Commercial	$5.18

diphtheria/tetanus/pertussis, acel (DTaP) 0.5 mL SDV [HHSC]

Facility

$163.29

Service Code	HCPCS 90700
Hospital Charge Code	2501179
Hospital Revenue Code	250
Min. Negotiated Rate	$138.80
Max. Negotiated Rate	$158.39
Rate for Payer: Cash Price	$106.14
Rate for Payer: Health Management Network Commercial	$138.80
Rate for Payer: Kaiser Permanente Commercial	$146.96
Rate for Payer: MDX Hawaii PPO	$158.39

diphtheria/tetanus/pertussis, acel (DTaP) 0.5 mL SDV [HHSC]

Facility

$163.29

Service Code	HCPCS 90700
Hospital Charge Code	2501179
Hospital Revenue Code	636
Min. Negotiated Rate	$32.42
Max. Negotiated Rate	$158.39
Rate for Payer: AlohaCare Medicaid	$81.64
Rate for Payer: AlohaCare Medicare	$81.64
Rate for Payer: Cash Price	$106.14
Rate for Payer: Cash Price	$106.14
Rate for Payer: Devoted Health Medicare	$89.81
Rate for Payer: Hawaii Medical Service Association ABD	$32.42
Rate for Payer: Hawaii Medical Service Association Medicare	$81.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.42
Rate for Payer: Hawaii Western Management Group Commercial	$155.13
Rate for Payer: Health Management Network Commercial	$138.80
Rate for Payer: Humana Medicare	$81.64
Rate for Payer: Kaiser Permanente Commercial	$146.96
Rate for Payer: Kaiser Permanente Medicaid	$83.28
Rate for Payer: Kaiser Permanente Medicare	$81.64
Rate for Payer: MDX Hawaii PPO	$158.39
Rate for Payer: Ohana Health Plan Medicaid	$81.64
Rate for Payer: Ohana Health Plan Medicare	$81.64
Rate for Payer: UnitedHealthcare Medicaid	$97.97
Rate for Payer: UnitedHealthcare Medicare	$81.64
Rate for Payer: University Health Alliance Commercial	$91.44

Direct Antiglobulin Test (C3)

Facility

$49.00

Service Code	HCPCS 86880
Hospital Charge Code	12499856
Hospital Revenue Code	302
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$31.85
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: MDX Hawaii PPO	$47.53

Direct Antiglobulin Test (C3)

Facility

$49.00

Service Code	HCPCS 86880
Hospital Charge Code	12499856
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$47.53
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: AlohaCare Medicare	$24.50
Rate for Payer: Cash Price	$31.85
Rate for Payer: Cash Price	$31.85
Rate for Payer: Devoted Health Medicare	$26.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.42
Rate for Payer: Hawaii Medical Service Association Commercial	$6.74
Rate for Payer: Hawaii Medical Service Association Medicare	$24.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.79
Rate for Payer: Hawaii Western Management Group Commercial	$5.39
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Humana Medicare	$24.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: Kaiser Permanente Medicare	$24.50
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: Ohana Health Plan Medicare	$24.50
Rate for Payer: UnitedHealthcare Medicaid	$7.42
Rate for Payer: UnitedHealthcare Medicare	$24.50
Rate for Payer: University Health Alliance Commercial	$13.88

Direct Antiglobulin Test (IgG)

Facility

$49.00

Service Code	HCPCS 86880
Hospital Charge Code	12499848
Hospital Revenue Code	302
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$31.85
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: MDX Hawaii PPO	$47.53

Direct Antiglobulin Test (IgG)

Facility

$49.00

Service Code	HCPCS 86880
Hospital Charge Code	12499848
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$47.53
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: AlohaCare Medicare	$24.50
Rate for Payer: Cash Price	$31.85
Rate for Payer: Cash Price	$31.85
Rate for Payer: Devoted Health Medicare	$26.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.42
Rate for Payer: Hawaii Medical Service Association Commercial	$6.74
Rate for Payer: Hawaii Medical Service Association Medicare	$24.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.79
Rate for Payer: Hawaii Western Management Group Commercial	$5.39
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Humana Medicare	$24.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: Kaiser Permanente Medicare	$24.50
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: Ohana Health Plan Medicare	$24.50
Rate for Payer: UnitedHealthcare Medicaid	$7.42
Rate for Payer: UnitedHealthcare Medicare	$24.50
Rate for Payer: University Health Alliance Commercial	$13.88

Direct Coombs FSI

Facility

$126.00

Service Code	HCPCS 86880
Hospital Charge Code	8128069
Hospital Revenue Code	302
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

Direct Coombs FSI

Facility

$126.00

Service Code	HCPCS 86880
Hospital Charge Code	8128069
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association ABD	$7.42
Rate for Payer: Hawaii Medical Service Association Commercial	$6.74
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.79
Rate for Payer: Hawaii Western Management Group Commercial	$5.39
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$7.42
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$13.88

DIRECT TO OBS CHARGE

Facility

$887.00

Service Code	HCPCS G0379
Hospital Charge Code	8281148
Hospital Revenue Code	762
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$576.55
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

DIRECT TO OBS CHARGE

Facility

$887.00

Service Code	HCPCS G0379
Hospital Charge Code	8281148
Hospital Revenue Code	762
Min. Negotiated Rate	$443.50
Max. Negotiated Rate	$1,200.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$443.50
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Devoted Health Medicare	$487.85
Rate for Payer: Hawaii Medical Service Association Commercial	$1,200.00
Rate for Payer: Hawaii Medical Service Association Medicare	$443.50
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$443.50
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$452.37
Rate for Payer: Kaiser Permanente Medicare	$443.50
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$443.50
Rate for Payer: Ohana Health Plan Medicare	$443.50
Rate for Payer: UnitedHealthcare Medicaid	$459.83
Rate for Payer: UnitedHealthcare Medicare	$443.50
Rate for Payer: University Health Alliance Commercial	$646.53

Disk Diffusion Susceptibility

Facility

$104.00

Service Code	HCPCS 87184
Hospital Charge Code	12499847
Hospital Revenue Code	306
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

Disk Diffusion Susceptibility

Facility

$104.00

Service Code	HCPCS 87184
Hospital Charge Code	12499847
Hospital Revenue Code	306
Min. Negotiated Rate	$7.48
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	$9.53
Rate for Payer: Hawaii Medical Service Association Commercial	$9.35
Rate for Payer: Hawaii Medical Service Association Medicare	$52.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.01
Rate for Payer: Hawaii Western Management Group Commercial	$7.48
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	$9.53
Rate for Payer: UnitedHealthcare Medicare	$52.00
Rate for Payer: University Health Alliance Commercial	$17.82

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$31,926.59

Service Code	MSDRG 442
Min. Negotiated Rate	$31,926.59
Max. Negotiated Rate	$31,926.59
Rate for Payer: Hawaii Medical Service Association Commercial	$31,926.59

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$31,926.59

Service Code	MSDRG 441
Min. Negotiated Rate	$31,926.59
Max. Negotiated Rate	$31,926.59
Rate for Payer: Hawaii Medical Service Association Commercial	$31,926.59

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$23,085.75

Service Code	MSDRG 443
Min. Negotiated Rate	$23,085.75
Max. Negotiated Rate	$23,085.75
Rate for Payer: Hawaii Medical Service Association Commercial	$23,085.75

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC

Facility

$24,958.21

Service Code	MSDRG 439
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC

Facility

$24,958.21

Service Code	MSDRG 438
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC

Facility

$24,958.21

Service Code	MSDRG 440
Min. Negotiated Rate	$24,958.21
Max. Negotiated Rate	$24,958.21
Rate for Payer: Hawaii Medical Service Association Commercial	$24,958.21

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility

$21,118.48

Service Code	MSDRG 883
Min. Negotiated Rate	$21,118.48
Max. Negotiated Rate	$21,118.48
Rate for Payer: Hawaii Medical Service Association Commercial	$21,118.48

DISORDERS OF THE BILIARY TRACT WITH CC

Facility

$25,124.12

Service Code	MSDRG 445
Min. Negotiated Rate	$25,124.12
Max. Negotiated Rate	$25,124.12
Rate for Payer: Hawaii Medical Service Association Commercial	$25,124.12

DISORDERS OF THE BILIARY TRACT WITH MCC

Facility

$25,645.56

Service Code	MSDRG 444
Min. Negotiated Rate	$25,645.56
Max. Negotiated Rate	$25,645.56
Rate for Payer: Hawaii Medical Service Association Commercial	$25,645.56

DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC

Facility

$16,567.70

Service Code	MSDRG 446
Min. Negotiated Rate	$16,567.70
Max. Negotiated Rate	$16,567.70
Rate for Payer: Hawaii Medical Service Association Commercial	$16,567.70

DISP LEG HOLDERS

Facility

$66.00

Hospital Charge Code	9916426
Hospital Revenue Code	270
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02

Know your out-of-pocket cost for care.

All Charges