Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Fingers minimum of 2 Views

Facility

$325.00

Service Code	HCPCS 73140 LT
Hospital Charge Code	1170151
Hospital Revenue Code	320
Min. Negotiated Rate	$276.25
Max. Negotiated Rate	$315.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Kaiser Permanente Commercial	$292.50
Rate for Payer: MDX Hawaii PPO	$315.25

Fingers minimum of 2 Views

Facility

$325.00

Service Code	HCPCS 73140 LT
Hospital Charge Code	1170151
Hospital Revenue Code	320
Min. Negotiated Rate	$14.98
Max. Negotiated Rate	$315.25
Rate for Payer: AlohaCare Medicaid	$162.50
Rate for Payer: AlohaCare Medicare	$162.50
Rate for Payer: Cash Price	$211.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Devoted Health Medicare	$178.75
Rate for Payer: Hawaii Medical Service Association ABD	$14.98
Rate for Payer: Hawaii Medical Service Association Medicare	$162.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.73
Rate for Payer: Hawaii Western Management Group Commercial	$308.75
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Humana Medicare	$162.50
Rate for Payer: Kaiser Permanente Commercial	$292.50
Rate for Payer: Kaiser Permanente Medicaid	$165.75
Rate for Payer: Kaiser Permanente Medicare	$162.50
Rate for Payer: MDX Hawaii PPO	$315.25
Rate for Payer: Ohana Health Plan Medicaid	$162.50
Rate for Payer: Ohana Health Plan Medicare	$162.50
Rate for Payer: UnitedHealthcare Medicaid	$14.98
Rate for Payer: UnitedHealthcare Medicare	$162.50
Rate for Payer: University Health Alliance Commercial	$54.96

First Vaccine 90471 - Admin Immunization charge

Professional

Both

$91.00

Service Code	HCPCS 90471
Hospital Charge Code	12139185
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$77.35
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

First Vaccine 90471 - Admin Immunization charge

Facility

$211.00

Service Code	HCPCS 90471
Hospital Charge Code	12139185
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$204.67
Rate for Payer: AlohaCare Medicaid	$105.50
Rate for Payer: AlohaCare Medicare	$105.50
Rate for Payer: Cash Price	$137.15
Rate for Payer: Cash Price	$137.15
Rate for Payer: Devoted Health Medicare	$116.05
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$105.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$200.45
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Humana Medicare	$105.50
Rate for Payer: Kaiser Permanente Commercial	$189.90
Rate for Payer: Kaiser Permanente Medicaid	$107.61
Rate for Payer: Kaiser Permanente Medicare	$105.50
Rate for Payer: MDX Hawaii PPO	$204.67
Rate for Payer: Ohana Health Plan Medicaid	$105.50
Rate for Payer: Ohana Health Plan Medicare	$105.50
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$105.50
Rate for Payer: University Health Alliance Commercial	$118.16

First Vaccine 90471 - Admin Immunization charge

Facility

$211.00

Service Code	HCPCS 90471
Hospital Charge Code	12139185
Hospital Revenue Code	771
Min. Negotiated Rate	$179.35
Max. Negotiated Rate	$204.67
Rate for Payer: Cash Price	$137.15
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Kaiser Permanente Commercial	$189.90
Rate for Payer: MDX Hawaii PPO	$204.67

First Vaccine 90471 - Admin Immunization Charge

Facility

$168.00

Service Code	HCPCS 90471
Hospital Charge Code	12304380
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$162.96
Rate for Payer: AlohaCare Medicaid	$84.00
Rate for Payer: AlohaCare Medicare	$84.00
Rate for Payer: Cash Price	$109.20
Rate for Payer: Cash Price	$109.20
Rate for Payer: Devoted Health Medicare	$92.40
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$84.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.56
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Humana Medicare	$84.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicare	$84.00
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: Ohana Health Plan Medicaid	$84.00
Rate for Payer: Ohana Health Plan Medicare	$84.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$84.00
Rate for Payer: University Health Alliance Commercial	$94.08

First Vaccine 90471 - Admin Immunization Charge

Professional

Both

$91.00

Service Code	HCPCS 90471
Hospital Charge Code	12304380
Hospital Revenue Code	771
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$77.35
Rate for Payer: AlohaCare Medicare	$24.10
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$26.51
Rate for Payer: Hawaii Medical Service Association Medicare	$24.10
Rate for Payer: Hawaii Western Management Group Commercial	$18.00
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$28.92
Rate for Payer: Kaiser Permanente Medicaid	$28.92
Rate for Payer: Kaiser Permanente Medicare	$28.92
Rate for Payer: Ohana Health Plan Medicare	$24.10
Rate for Payer: UnitedHealthcare Medicare	$24.10

First Vaccine 90471 - Admin Immunization Charge

Facility

$168.00

Service Code	HCPCS 90471
Hospital Charge Code	12304380
Hospital Revenue Code	771
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: MDX Hawaii PPO	$162.96

FIXATION NUT WASHER,RETROGRADE FEM NAIL

Facility

$1,453.00

Service Code	HCPCS C1713
Hospital Charge Code	12984244
Hospital Revenue Code	278
Min. Negotiated Rate	$813.68
Max. Negotiated Rate	$1,409.41
Rate for Payer: Cash Price	$944.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,017.10
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: Kaiser Permanente Commercial	$1,307.70
Rate for Payer: MDX Hawaii PPO	$1,409.41
Rate for Payer: University Health Alliance Commercial	$813.68

FIXATION NUT WASHER,RETROGRADE FEM NAIL

Facility

$1,453.00

Service Code	HCPCS C1713
Hospital Charge Code	12984244
Hospital Revenue Code	278
Min. Negotiated Rate	$726.50
Max. Negotiated Rate	$1,409.41
Rate for Payer: AlohaCare Medicaid	$726.50
Rate for Payer: AlohaCare Medicare	$726.50
Rate for Payer: Cash Price	$944.45
Rate for Payer: Devoted Health Medicare	$799.15
Rate for Payer: Hawaii Medical Service Association Medicare	$726.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,017.10
Rate for Payer: Health Management Network Commercial	$1,235.05
Rate for Payer: Humana Medicare	$726.50
Rate for Payer: Kaiser Permanente Commercial	$1,307.70
Rate for Payer: Kaiser Permanente Medicaid	$741.03
Rate for Payer: Kaiser Permanente Medicare	$726.50
Rate for Payer: MDX Hawaii PPO	$1,409.41
Rate for Payer: Ohana Health Plan Medicaid	$726.50
Rate for Payer: Ohana Health Plan Medicare	$726.50
Rate for Payer: UnitedHealthcare Medicare	$726.50
Rate for Payer: University Health Alliance Commercial	$813.68

FIXATN SCREW WASHER,RETROGRADE FEM NAIL

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12984240
Hospital Revenue Code	278
Min. Negotiated Rate	$290.64
Max. Negotiated Rate	$503.43
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: University Health Alliance Commercial	$290.64

FIXATN SCREW WASHER,RETROGRADE FEM NAIL

Facility

$519.00

Service Code	HCPCS C1713
Hospital Charge Code	12984240
Hospital Revenue Code	278
Min. Negotiated Rate	$259.50
Max. Negotiated Rate	$503.43
Rate for Payer: AlohaCare Medicaid	$259.50
Rate for Payer: AlohaCare Medicare	$259.50
Rate for Payer: Cash Price	$337.35
Rate for Payer: Devoted Health Medicare	$285.45
Rate for Payer: Hawaii Medical Service Association Medicare	$259.50
Rate for Payer: Hawaii Western Management Group Commercial	$363.30
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Humana Medicare	$259.50
Rate for Payer: Kaiser Permanente Commercial	$467.10
Rate for Payer: Kaiser Permanente Medicaid	$264.69
Rate for Payer: Kaiser Permanente Medicare	$259.50
Rate for Payer: MDX Hawaii PPO	$503.43
Rate for Payer: Ohana Health Plan Medicaid	$259.50
Rate for Payer: Ohana Health Plan Medicare	$259.50
Rate for Payer: UnitedHealthcare Medicare	$259.50
Rate for Payer: University Health Alliance Commercial	$290.64

FK506 (Prograf) FSI

Facility

$157.00

Service Code	HCPCS 80197
Hospital Charge Code	8228868
Hospital Revenue Code	301
Min. Negotiated Rate	$133.45
Max. Negotiated Rate	$152.29
Rate for Payer: Cash Price	$102.05
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: MDX Hawaii PPO	$152.29

FK506 (Prograf) FSI

Facility

$157.00

Service Code	HCPCS 80197
Hospital Charge Code	8228868
Hospital Revenue Code	301
Min. Negotiated Rate	$13.73
Max. Negotiated Rate	$152.29
Rate for Payer: AlohaCare Medicaid	$78.50
Rate for Payer: AlohaCare Medicare	$78.50
Rate for Payer: Cash Price	$102.05
Rate for Payer: Cash Price	$102.05
Rate for Payer: Devoted Health Medicare	$86.35
Rate for Payer: Hawaii Medical Service Association ABD	$18.97
Rate for Payer: Hawaii Medical Service Association Commercial	$17.16
Rate for Payer: Hawaii Medical Service Association Medicare	$78.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.92
Rate for Payer: Hawaii Western Management Group Commercial	$13.73
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Humana Medicare	$78.50
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: Kaiser Permanente Medicaid	$80.07
Rate for Payer: Kaiser Permanente Medicare	$78.50
Rate for Payer: MDX Hawaii PPO	$152.29
Rate for Payer: Ohana Health Plan Medicaid	$78.50
Rate for Payer: Ohana Health Plan Medicare	$78.50
Rate for Payer: UnitedHealthcare Medicaid	$18.97
Rate for Payer: UnitedHealthcare Medicare	$78.50
Rate for Payer: University Health Alliance Commercial	$35.46

Flu AB PCR Rfx CoV-2 FSI

Facility

$947.00

Service Code	HCPCS 87502
Hospital Charge Code	8860987
Hospital Revenue Code	306
Min. Negotiated Rate	$95.80
Max. Negotiated Rate	$918.59
Rate for Payer: AlohaCare Medicaid	$473.50
Rate for Payer: AlohaCare Medicare	$473.50
Rate for Payer: Cash Price	$615.55
Rate for Payer: Cash Price	$615.55
Rate for Payer: Devoted Health Medicare	$520.85
Rate for Payer: Hawaii Medical Service Association ABD	$119.75
Rate for Payer: Hawaii Medical Service Association Commercial	$119.75
Rate for Payer: Hawaii Medical Service Association Medicare	$473.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117.54
Rate for Payer: Hawaii Western Management Group Commercial	$95.80
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Humana Medicare	$473.50
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: Kaiser Permanente Medicaid	$482.97
Rate for Payer: Kaiser Permanente Medicare	$473.50
Rate for Payer: MDX Hawaii PPO	$918.59
Rate for Payer: Ohana Health Plan Medicaid	$473.50
Rate for Payer: Ohana Health Plan Medicare	$473.50
Rate for Payer: UnitedHealthcare Medicaid	$119.75
Rate for Payer: UnitedHealthcare Medicare	$473.50
Rate for Payer: University Health Alliance Commercial	$221.54

Flu AB PCR Rfx CoV-2 FSI

Facility

$947.00

Service Code	HCPCS 87502
Hospital Charge Code	8860987
Hospital Revenue Code	306
Min. Negotiated Rate	$804.95
Max. Negotiated Rate	$918.59
Rate for Payer: Cash Price	$615.55
Rate for Payer: Health Management Network Commercial	$804.95
Rate for Payer: Kaiser Permanente Commercial	$852.30
Rate for Payer: MDX Hawaii PPO	$918.59

fluconazole 150 mg tablet [HHSC]

Facility

$76.71

Service Code	NDC 68001025320
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$65.20
Max. Negotiated Rate	$74.41
Rate for Payer: Cash Price	$49.86
Rate for Payer: Health Management Network Commercial	$65.20
Rate for Payer: Kaiser Permanente Commercial	$69.04
Rate for Payer: MDX Hawaii PPO	$74.41

fluconazole 150 mg tablet [HHSC]

Facility

$76.71

Service Code	NDC 68462010340
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$38.35
Max. Negotiated Rate	$74.41
Rate for Payer: AlohaCare Medicaid	$38.35
Rate for Payer: AlohaCare Medicare	$38.35
Rate for Payer: Cash Price	$49.86
Rate for Payer: Devoted Health Medicare	$42.19
Rate for Payer: Hawaii Medical Service Association Medicare	$38.35
Rate for Payer: Hawaii Western Management Group Commercial	$72.87
Rate for Payer: Health Management Network Commercial	$65.20
Rate for Payer: Humana Medicare	$38.35
Rate for Payer: Kaiser Permanente Commercial	$69.04
Rate for Payer: Kaiser Permanente Medicaid	$39.12
Rate for Payer: Kaiser Permanente Medicare	$38.35
Rate for Payer: MDX Hawaii PPO	$74.41
Rate for Payer: Ohana Health Plan Medicaid	$38.35
Rate for Payer: Ohana Health Plan Medicare	$38.35
Rate for Payer: UnitedHealthcare Medicaid	$46.03
Rate for Payer: UnitedHealthcare Medicare	$38.35
Rate for Payer: University Health Alliance Commercial	$55.91

fluconazole 150 mg tablet [HHSC]

Facility

$76.71

Service Code	NDC 68001025317
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$65.20
Max. Negotiated Rate	$74.41
Rate for Payer: Cash Price	$49.86
Rate for Payer: Health Management Network Commercial	$65.20
Rate for Payer: Kaiser Permanente Commercial	$69.04
Rate for Payer: MDX Hawaii PPO	$74.41

fluconazole 150 mg tablet [HHSC]

Facility

$76.39

Service Code	NDC 57237000511
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$38.20
Max. Negotiated Rate	$74.10
Rate for Payer: AlohaCare Medicaid	$38.20
Rate for Payer: AlohaCare Medicare	$38.20
Rate for Payer: Cash Price	$49.65
Rate for Payer: Devoted Health Medicare	$42.01
Rate for Payer: Hawaii Medical Service Association Medicare	$38.20
Rate for Payer: Hawaii Western Management Group Commercial	$72.57
Rate for Payer: Health Management Network Commercial	$64.93
Rate for Payer: Humana Medicare	$38.20
Rate for Payer: Kaiser Permanente Commercial	$68.75
Rate for Payer: Kaiser Permanente Medicaid	$38.96
Rate for Payer: Kaiser Permanente Medicare	$38.20
Rate for Payer: MDX Hawaii PPO	$74.10
Rate for Payer: Ohana Health Plan Medicaid	$38.20
Rate for Payer: Ohana Health Plan Medicare	$38.20
Rate for Payer: UnitedHealthcare Medicaid	$45.83
Rate for Payer: UnitedHealthcare Medicare	$38.20
Rate for Payer: University Health Alliance Commercial	$55.68

fluconazole 150 mg tablet [HHSC]

Facility

$76.71

Service Code	NDC 68001025320
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$38.35
Max. Negotiated Rate	$74.41
Rate for Payer: AlohaCare Medicaid	$38.35
Rate for Payer: AlohaCare Medicare	$38.35
Rate for Payer: Cash Price	$49.86
Rate for Payer: Devoted Health Medicare	$42.19
Rate for Payer: Hawaii Medical Service Association Medicare	$38.35
Rate for Payer: Hawaii Western Management Group Commercial	$72.87
Rate for Payer: Health Management Network Commercial	$65.20
Rate for Payer: Humana Medicare	$38.35
Rate for Payer: Kaiser Permanente Commercial	$69.04
Rate for Payer: Kaiser Permanente Medicaid	$39.12
Rate for Payer: Kaiser Permanente Medicare	$38.35
Rate for Payer: MDX Hawaii PPO	$74.41
Rate for Payer: Ohana Health Plan Medicaid	$38.35
Rate for Payer: Ohana Health Plan Medicare	$38.35
Rate for Payer: UnitedHealthcare Medicaid	$46.03
Rate for Payer: UnitedHealthcare Medicare	$38.35
Rate for Payer: University Health Alliance Commercial	$55.91

fluconazole 150 mg tablet [HHSC]

Facility

$76.71

Service Code	NDC 68462010340
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$65.20
Max. Negotiated Rate	$74.41
Rate for Payer: Cash Price	$49.86
Rate for Payer: Health Management Network Commercial	$65.20
Rate for Payer: Kaiser Permanente Commercial	$69.04
Rate for Payer: MDX Hawaii PPO	$74.41

fluconazole 150 mg tablet [HHSC]

Facility

$76.71

Service Code	NDC 68001025317
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$38.35
Max. Negotiated Rate	$74.41
Rate for Payer: AlohaCare Medicaid	$38.35
Rate for Payer: AlohaCare Medicare	$38.35
Rate for Payer: Cash Price	$49.86
Rate for Payer: Devoted Health Medicare	$42.19
Rate for Payer: Hawaii Medical Service Association Medicare	$38.35
Rate for Payer: Hawaii Western Management Group Commercial	$72.87
Rate for Payer: Health Management Network Commercial	$65.20
Rate for Payer: Humana Medicare	$38.35
Rate for Payer: Kaiser Permanente Commercial	$69.04
Rate for Payer: Kaiser Permanente Medicaid	$39.12
Rate for Payer: Kaiser Permanente Medicare	$38.35
Rate for Payer: MDX Hawaii PPO	$74.41
Rate for Payer: Ohana Health Plan Medicaid	$38.35
Rate for Payer: Ohana Health Plan Medicare	$38.35
Rate for Payer: UnitedHealthcare Medicaid	$46.03
Rate for Payer: UnitedHealthcare Medicare	$38.35
Rate for Payer: University Health Alliance Commercial	$55.91

fluconazole 150 mg tablet [HHSC]

Facility

$76.39

Service Code	NDC 57237000511
Hospital Charge Code	2500329
Hospital Revenue Code	250
Min. Negotiated Rate	$64.93
Max. Negotiated Rate	$74.10
Rate for Payer: Cash Price	$49.65
Rate for Payer: Health Management Network Commercial	$64.93
Rate for Payer: Kaiser Permanente Commercial	$68.75
Rate for Payer: MDX Hawaii PPO	$74.10

Fluid Cell Count, Diff, Crystals FSI

Facility

$124.00

Service Code	HCPCS 89060
Hospital Charge Code	8117879
Hospital Revenue Code	309
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$80.60
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

Know your out-of-pocket cost for care.

All Charges