Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

etomidate 20 mg/10 ml vial [HHSC]

Facility

$18.68

Service Code	NDC 00143931010
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$15.88
Max. Negotiated Rate	$18.12
Rate for Payer: Cash Price	$12.14
Rate for Payer: Health Management Network Commercial	$15.88
Rate for Payer: Kaiser Permanente Commercial	$16.81
Rate for Payer: MDX Hawaii PPO	$18.12

etomidate 20 mg/10 ml vial [HHSC]

Facility

$41.82

Service Code	NDC 65219044510
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$35.55
Max. Negotiated Rate	$40.57
Rate for Payer: Cash Price	$27.18
Rate for Payer: Health Management Network Commercial	$35.55
Rate for Payer: Kaiser Permanente Commercial	$37.64
Rate for Payer: MDX Hawaii PPO	$40.57

etomidate 20 mg/10 ml vial [HHSC]

Facility

$46.03

Service Code	NDC 00143950610
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$23.02
Max. Negotiated Rate	$44.65
Rate for Payer: AlohaCare Medicaid	$23.02
Rate for Payer: AlohaCare Medicare	$23.02
Rate for Payer: Cash Price	$29.92
Rate for Payer: Devoted Health Medicare	$25.32
Rate for Payer: Hawaii Medical Service Association Medicare	$23.02
Rate for Payer: Hawaii Western Management Group Commercial	$43.73
Rate for Payer: Health Management Network Commercial	$39.13
Rate for Payer: Humana Medicare	$23.02
Rate for Payer: Kaiser Permanente Commercial	$41.43
Rate for Payer: Kaiser Permanente Medicaid	$23.48
Rate for Payer: Kaiser Permanente Medicare	$23.02
Rate for Payer: MDX Hawaii PPO	$44.65
Rate for Payer: Ohana Health Plan Medicaid	$23.02
Rate for Payer: Ohana Health Plan Medicare	$23.02
Rate for Payer: UnitedHealthcare Medicaid	$27.62
Rate for Payer: UnitedHealthcare Medicare	$23.02
Rate for Payer: University Health Alliance Commercial	$33.55

etomidate 20 mg/10 ml vial [HHSC]

Facility

$41.82

Service Code	NDC 65219044510
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$20.91
Max. Negotiated Rate	$40.57
Rate for Payer: AlohaCare Medicaid	$20.91
Rate for Payer: AlohaCare Medicare	$20.91
Rate for Payer: Cash Price	$27.18
Rate for Payer: Devoted Health Medicare	$23.00
Rate for Payer: Hawaii Medical Service Association Medicare	$20.91
Rate for Payer: Hawaii Western Management Group Commercial	$39.73
Rate for Payer: Health Management Network Commercial	$35.55
Rate for Payer: Humana Medicare	$20.91
Rate for Payer: Kaiser Permanente Commercial	$37.64
Rate for Payer: Kaiser Permanente Medicaid	$21.33
Rate for Payer: Kaiser Permanente Medicare	$20.91
Rate for Payer: MDX Hawaii PPO	$40.57
Rate for Payer: Ohana Health Plan Medicaid	$20.91
Rate for Payer: Ohana Health Plan Medicare	$20.91
Rate for Payer: UnitedHealthcare Medicaid	$25.09
Rate for Payer: UnitedHealthcare Medicare	$20.91
Rate for Payer: University Health Alliance Commercial	$30.48

etomidate 20 mg/10 ml vial [HHSC]

Facility

$18.68

Service Code	NDC 00143931010
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$9.34
Max. Negotiated Rate	$18.12
Rate for Payer: AlohaCare Medicaid	$9.34
Rate for Payer: AlohaCare Medicare	$9.34
Rate for Payer: Cash Price	$12.14
Rate for Payer: Devoted Health Medicare	$10.27
Rate for Payer: Hawaii Medical Service Association Medicare	$9.34
Rate for Payer: Hawaii Western Management Group Commercial	$17.75
Rate for Payer: Health Management Network Commercial	$15.88
Rate for Payer: Humana Medicare	$9.34
Rate for Payer: Kaiser Permanente Commercial	$16.81
Rate for Payer: Kaiser Permanente Medicaid	$9.53
Rate for Payer: Kaiser Permanente Medicare	$9.34
Rate for Payer: MDX Hawaii PPO	$18.12
Rate for Payer: Ohana Health Plan Medicaid	$9.34
Rate for Payer: Ohana Health Plan Medicare	$9.34
Rate for Payer: UnitedHealthcare Medicaid	$11.21
Rate for Payer: UnitedHealthcare Medicare	$9.34
Rate for Payer: University Health Alliance Commercial	$13.62

etomidate 20 mg/10 ml vial [HHSC]

Facility

$56.43

Service Code	NDC 55150022110
Hospital Charge Code	2500317
Hospital Revenue Code	250
Min. Negotiated Rate	$28.21
Max. Negotiated Rate	$54.74
Rate for Payer: AlohaCare Medicaid	$28.21
Rate for Payer: AlohaCare Medicare	$28.21
Rate for Payer: Cash Price	$36.68
Rate for Payer: Devoted Health Medicare	$31.04
Rate for Payer: Hawaii Medical Service Association Medicare	$28.21
Rate for Payer: Hawaii Western Management Group Commercial	$53.61
Rate for Payer: Health Management Network Commercial	$47.97
Rate for Payer: Humana Medicare	$28.21
Rate for Payer: Kaiser Permanente Commercial	$50.79
Rate for Payer: Kaiser Permanente Medicaid	$28.78
Rate for Payer: Kaiser Permanente Medicare	$28.21
Rate for Payer: MDX Hawaii PPO	$54.74
Rate for Payer: Ohana Health Plan Medicaid	$28.21
Rate for Payer: Ohana Health Plan Medicare	$28.21
Rate for Payer: UnitedHealthcare Medicaid	$33.86
Rate for Payer: UnitedHealthcare Medicare	$28.21
Rate for Payer: University Health Alliance Commercial	$41.13

Eval of Oral and Pharyngeal Swallowing Fx Chg

Facility

$521.00

Service Code	HCPCS 92610 GO,CO
Hospital Charge Code	8359326
Hospital Revenue Code	444
Min. Negotiated Rate	$442.85
Max. Negotiated Rate	$505.37
Rate for Payer: Cash Price	$338.65
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: MDX Hawaii PPO	$505.37

Eval of Oral and Pharyngeal Swallowing Fx Chg

Facility

$521.00

Service Code	HCPCS 92610 GO,CO
Hospital Charge Code	8171799
Hospital Revenue Code	444
Min. Negotiated Rate	$442.85
Max. Negotiated Rate	$505.37
Rate for Payer: Cash Price	$338.65
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: MDX Hawaii PPO	$505.37

Eval of Oral and Pharyngeal Swallowing Fx Chg

Facility

$521.00

Service Code	HCPCS 92610 GO,CO
Hospital Charge Code	8359326
Hospital Revenue Code	444
Min. Negotiated Rate	$88.36
Max. Negotiated Rate	$505.37
Rate for Payer: AlohaCare Medicaid	$260.50
Rate for Payer: AlohaCare Medicare	$260.50
Rate for Payer: Cash Price	$338.65
Rate for Payer: Cash Price	$338.65
Rate for Payer: Devoted Health Medicare	$286.55
Rate for Payer: Hawaii Medical Service Association Medicare	$260.50
Rate for Payer: Hawaii Western Management Group Commercial	$494.95
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Humana Medicare	$260.50
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: Kaiser Permanente Medicaid	$265.71
Rate for Payer: Kaiser Permanente Medicare	$260.50
Rate for Payer: MDX Hawaii PPO	$505.37
Rate for Payer: Ohana Health Plan Medicaid	$260.50
Rate for Payer: Ohana Health Plan Medicare	$260.50
Rate for Payer: UnitedHealthcare Medicaid	$88.36
Rate for Payer: UnitedHealthcare Medicare	$260.50
Rate for Payer: University Health Alliance Commercial	$291.76

Eval of Oral and Pharyngeal Swallowing Fx Chg

Facility

$521.00

Service Code	HCPCS 92610 GO,CO
Hospital Charge Code	8171799
Hospital Revenue Code	444
Min. Negotiated Rate	$88.36
Max. Negotiated Rate	$505.37
Rate for Payer: AlohaCare Medicaid	$260.50
Rate for Payer: AlohaCare Medicare	$260.50
Rate for Payer: Cash Price	$338.65
Rate for Payer: Cash Price	$338.65
Rate for Payer: Devoted Health Medicare	$286.55
Rate for Payer: Hawaii Medical Service Association Medicare	$260.50
Rate for Payer: Hawaii Western Management Group Commercial	$494.95
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Humana Medicare	$260.50
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: Kaiser Permanente Medicaid	$265.71
Rate for Payer: Kaiser Permanente Medicare	$260.50
Rate for Payer: MDX Hawaii PPO	$505.37
Rate for Payer: Ohana Health Plan Medicaid	$260.50
Rate for Payer: Ohana Health Plan Medicare	$260.50
Rate for Payer: UnitedHealthcare Medicaid	$88.36
Rate for Payer: UnitedHealthcare Medicare	$260.50
Rate for Payer: University Health Alliance Commercial	$291.76

EVIVA BREAST BX NEEDLE, PETITE 9GX10CM

Facility

$1,078.00

Hospital Charge Code	12925600
Hospital Revenue Code	272
Min. Negotiated Rate	$916.30
Max. Negotiated Rate	$1,045.66
Rate for Payer: Cash Price	$700.70
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: MDX Hawaii PPO	$1,045.66

EVIVA BREAST BX NEEDLE, PETITE 9GX10CM

Facility

$1,078.00

Hospital Charge Code	12925600
Hospital Revenue Code	272
Min. Negotiated Rate	$539.00
Max. Negotiated Rate	$1,045.66
Rate for Payer: AlohaCare Medicaid	$539.00
Rate for Payer: AlohaCare Medicare	$539.00
Rate for Payer: Cash Price	$700.70
Rate for Payer: Devoted Health Medicare	$592.90
Rate for Payer: Hawaii Medical Service Association Medicare	$539.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,024.10
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Humana Medicare	$539.00
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: Kaiser Permanente Medicaid	$549.78
Rate for Payer: Kaiser Permanente Medicare	$539.00
Rate for Payer: MDX Hawaii PPO	$1,045.66
Rate for Payer: Ohana Health Plan Medicaid	$539.00
Rate for Payer: Ohana Health Plan Medicare	$539.00
Rate for Payer: UnitedHealthcare Medicare	$539.00
Rate for Payer: University Health Alliance Commercial	$785.75

EVIVA BREAST BX NEEDLE, STANDARD 9GX13CM

Facility

$1,078.00

Hospital Charge Code	12925598
Hospital Revenue Code	272
Min. Negotiated Rate	$916.30
Max. Negotiated Rate	$1,045.66
Rate for Payer: Cash Price	$700.70
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: MDX Hawaii PPO	$1,045.66

EVIVA BREAST BX NEEDLE, STANDARD 9GX13CM

Facility

$1,078.00

Hospital Charge Code	12925598
Hospital Revenue Code	272
Min. Negotiated Rate	$539.00
Max. Negotiated Rate	$1,045.66
Rate for Payer: AlohaCare Medicaid	$539.00
Rate for Payer: AlohaCare Medicare	$539.00
Rate for Payer: Cash Price	$700.70
Rate for Payer: Devoted Health Medicare	$592.90
Rate for Payer: Hawaii Medical Service Association Medicare	$539.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,024.10
Rate for Payer: Health Management Network Commercial	$916.30
Rate for Payer: Humana Medicare	$539.00
Rate for Payer: Kaiser Permanente Commercial	$970.20
Rate for Payer: Kaiser Permanente Medicaid	$549.78
Rate for Payer: Kaiser Permanente Medicare	$539.00
Rate for Payer: MDX Hawaii PPO	$1,045.66
Rate for Payer: Ohana Health Plan Medicaid	$539.00
Rate for Payer: Ohana Health Plan Medicare	$539.00
Rate for Payer: UnitedHealthcare Medicare	$539.00
Rate for Payer: University Health Alliance Commercial	$785.75

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$61,625.20

Service Code	MSDRG 933
Min. Negotiated Rate	$61,625.20
Max. Negotiated Rate	$61,625.20
Rate for Payer: Hawaii Medical Service Association Commercial	$61,625.20

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$382,502.88

Service Code	MSDRG 927
Min. Negotiated Rate	$382,502.88
Max. Negotiated Rate	$382,502.88
Rate for Payer: Hawaii Medical Service Association Commercial	$382,502.88

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$45,650.05

Service Code	MSDRG 982
Min. Negotiated Rate	$45,650.05
Max. Negotiated Rate	$45,650.05
Rate for Payer: Hawaii Medical Service Association Commercial	$45,650.05

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$76,510.06

Service Code	MSDRG 981
Min. Negotiated Rate	$76,510.06
Max. Negotiated Rate	$76,510.06
Rate for Payer: Hawaii Medical Service Association Commercial	$76,510.06

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$30,291.16

Service Code	MSDRG 983
Min. Negotiated Rate	$30,291.16
Max. Negotiated Rate	$30,291.16
Rate for Payer: Hawaii Medical Service Association Commercial	$30,291.16

EXTRACRANIAL PROCEDURES WITH CC

Facility

$54,135.37

Service Code	MSDRG 038
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$54,135.37
Rate for Payer: Hawaii Medical Service Association Commercial	$54,135.37
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$65,038.29

Service Code	MSDRG 037
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$65,038.29
Rate for Payer: Hawaii Medical Service Association Commercial	$65,038.29
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$42,142.16

Service Code	MSDRG 039
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$42,142.16
Rate for Payer: Hawaii Medical Service Association Commercial	$42,142.16
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$17,800.20

Service Code	MSDRG 115
Min. Negotiated Rate	$10,400.00
Max. Negotiated Rate	$17,800.20
Rate for Payer: Hawaii Medical Service Association Commercial	$17,800.20
Rate for Payer: University Health Alliance Commercial	$10,400.00

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$271,980.45

Service Code	MSDRG 790
Min. Negotiated Rate	$271,980.45
Max. Negotiated Rate	$271,980.45
Rate for Payer: Hawaii Medical Service Association Commercial	$271,980.45

EYE EXAM† - 00148

Professional

Both

$191.00

Hospital Charge Code	8970861
Hospital Revenue Code	963
Min. Negotiated Rate	$162.35
Max. Negotiated Rate	$162.35
Rate for Payer: Cash Price	$124.15
Rate for Payer: Health Management Network Commercial	$162.35

Know your out-of-pocket cost for care.

All Charges