Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Glucose (Venous) POCT

Facility

$49.00

Service Code	HCPCS 82947
Hospital Charge Code	9364732
Hospital Revenue Code	301
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

GRAFT, SKIN DERMACARRIER II, 1.5:1

Facility

$169.00

Hospital Charge Code	8274154
Hospital Revenue Code	272
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$109.85
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: MDX Hawaii PPO	$163.93

GRAFT, SKIN DERMACARRIER II, 1.5:1

Facility

$169.00

Hospital Charge Code	8274154
Hospital Revenue Code	272
Min. Negotiated Rate	$84.50
Max. Negotiated Rate	$163.93
Rate for Payer: AlohaCare Medicaid	$84.50
Rate for Payer: AlohaCare Medicare	$84.50
Rate for Payer: Cash Price	$109.85
Rate for Payer: Devoted Health Medicare	$92.95
Rate for Payer: Hawaii Medical Service Association Medicare	$84.50
Rate for Payer: Hawaii Western Management Group Commercial	$160.55
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Humana Medicare	$84.50
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicare	$84.50
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: Ohana Health Plan Medicaid	$84.50
Rate for Payer: Ohana Health Plan Medicare	$84.50
Rate for Payer: UnitedHealthcare Medicare	$84.50
Rate for Payer: University Health Alliance Commercial	$123.18

GRAFT, SKIN DERMACARRIER II, 3: 1

Facility

$2,025.00

Hospital Charge Code	8274155
Hospital Revenue Code	272
Min. Negotiated Rate	$1,012.50
Max. Negotiated Rate	$1,964.25
Rate for Payer: AlohaCare Medicaid	$1,012.50
Rate for Payer: AlohaCare Medicare	$1,012.50
Rate for Payer: Cash Price	$1,316.25
Rate for Payer: Devoted Health Medicare	$1,113.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,012.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,923.75
Rate for Payer: Health Management Network Commercial	$1,721.25
Rate for Payer: Humana Medicare	$1,012.50
Rate for Payer: Kaiser Permanente Commercial	$1,822.50
Rate for Payer: Kaiser Permanente Medicaid	$1,032.75
Rate for Payer: Kaiser Permanente Medicare	$1,012.50
Rate for Payer: MDX Hawaii PPO	$1,964.25
Rate for Payer: Ohana Health Plan Medicaid	$1,012.50
Rate for Payer: Ohana Health Plan Medicare	$1,012.50
Rate for Payer: UnitedHealthcare Medicare	$1,012.50
Rate for Payer: University Health Alliance Commercial	$1,476.02

GRAFT, SKIN DERMACARRIER II, 3: 1

Facility

$2,025.00

Hospital Charge Code	8274155
Hospital Revenue Code	272
Min. Negotiated Rate	$1,721.25
Max. Negotiated Rate	$1,964.25
Rate for Payer: Cash Price	$1,316.25
Rate for Payer: Health Management Network Commercial	$1,721.25
Rate for Payer: Kaiser Permanente Commercial	$1,822.50
Rate for Payer: MDX Hawaii PPO	$1,964.25

GRAFT, SKIN DERMATOME BLADES

Facility

$214.00

Hospital Charge Code	8274156
Hospital Revenue Code	272
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$139.10
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: MDX Hawaii PPO	$207.58

GRAFT, SKIN DERMATOME BLADES

Facility

$214.00

Hospital Charge Code	8274156
Hospital Revenue Code	272
Min. Negotiated Rate	$107.00
Max. Negotiated Rate	$207.58
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$155.98

Gram Smear FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228874
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$11.03

Gram Smear FSI

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8228874
Hospital Revenue Code	306
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Gram Stain REF

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8159945
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$64.99
Rate for Payer: AlohaCare Medicaid	$33.50
Rate for Payer: AlohaCare Medicare	$33.50
Rate for Payer: Cash Price	$43.55
Rate for Payer: Cash Price	$43.55
Rate for Payer: Devoted Health Medicare	$36.85
Rate for Payer: Hawaii Medical Service Association ABD	$5.90
Rate for Payer: Hawaii Medical Service Association Commercial	$5.34
Rate for Payer: Hawaii Medical Service Association Medicare	$33.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.20
Rate for Payer: Hawaii Western Management Group Commercial	$4.27
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Humana Medicare	$33.50
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: Kaiser Permanente Medicaid	$34.17
Rate for Payer: Kaiser Permanente Medicare	$33.50
Rate for Payer: MDX Hawaii PPO	$64.99
Rate for Payer: Ohana Health Plan Medicaid	$33.50
Rate for Payer: Ohana Health Plan Medicare	$33.50
Rate for Payer: UnitedHealthcare Medicaid	$5.90
Rate for Payer: UnitedHealthcare Medicare	$33.50
Rate for Payer: University Health Alliance Commercial	$11.03

Gram Stain REF

Facility

$67.00

Service Code	HCPCS 87205
Hospital Charge Code	8159945
Hospital Revenue Code	306
Min. Negotiated Rate	$56.95
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$43.55
Rate for Payer: Health Management Network Commercial	$56.95
Rate for Payer: Kaiser Permanente Commercial	$60.30
Rate for Payer: MDX Hawaii PPO	$64.99

Group B Strep Carrier Culture FSI

Facility

$90.00

Service Code	HCPCS 87081
Hospital Charge Code	8117928
Hospital Revenue Code	306
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$87.30
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: MDX Hawaii PPO	$87.30

Group B Strep Carrier Culture FSI

Facility

$90.00

Service Code	HCPCS 87081
Hospital Charge Code	8117928
Hospital Revenue Code	306
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$87.30
Rate for Payer: AlohaCare Medicaid	$45.00
Rate for Payer: AlohaCare Medicare	$45.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Devoted Health Medicare	$49.50
Rate for Payer: Hawaii Medical Service Association ABD	$9.16
Rate for Payer: Hawaii Medical Service Association Commercial	$8.29
Rate for Payer: Hawaii Medical Service Association Medicare	$45.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.62
Rate for Payer: Hawaii Western Management Group Commercial	$6.63
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Humana Medicare	$45.00
Rate for Payer: Kaiser Permanente Commercial	$81.00
Rate for Payer: Kaiser Permanente Medicaid	$45.90
Rate for Payer: Kaiser Permanente Medicare	$45.00
Rate for Payer: MDX Hawaii PPO	$87.30
Rate for Payer: Ohana Health Plan Medicaid	$45.00
Rate for Payer: Ohana Health Plan Medicare	$45.00
Rate for Payer: UnitedHealthcare Medicaid	$9.16
Rate for Payer: UnitedHealthcare Medicare	$45.00
Rate for Payer: University Health Alliance Commercial	$17.13

Group B Strep DNA PCR FSI

Facility

$392.00

Service Code	HCPCS 87653
Hospital Charge Code	8117929
Hospital Revenue Code	306
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

Group B Strep DNA PCR FSI

Facility

$392.00

Service Code	HCPCS 87653
Hospital Charge Code	8117929
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association ABD	$49.04
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.49
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$90.72

Group Therapy Charge

Facility

$132.00

Service Code	HCPCS 97150 GP,59
Hospital Charge Code	8111706
Hospital Revenue Code	420
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

Group Therapy Charge

Facility

$132.00

Service Code	HCPCS 97150 GP,59
Hospital Charge Code	8111706
Hospital Revenue Code	420
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$73.92

Group Therapy Provided

Facility

$132.00

Service Code	HCPCS 97150 GP,CQ
Hospital Charge Code	8123863
Hospital Revenue Code	430
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$128.04
Rate for Payer: AlohaCare Medicaid	$66.00
Rate for Payer: AlohaCare Medicare	$66.00
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$72.60
Rate for Payer: Hawaii Medical Service Association Medicare	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$125.40
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Humana Medicare	$66.00
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: Kaiser Permanente Medicaid	$67.32
Rate for Payer: Kaiser Permanente Medicare	$66.00
Rate for Payer: MDX Hawaii PPO	$128.04
Rate for Payer: Ohana Health Plan Medicaid	$66.00
Rate for Payer: Ohana Health Plan Medicare	$66.00
Rate for Payer: UnitedHealthcare Medicaid	$14.78
Rate for Payer: UnitedHealthcare Medicare	$66.00
Rate for Payer: University Health Alliance Commercial	$73.92

Group Therapy Provided

Facility

$132.00

Service Code	HCPCS 97150 GP,CQ
Hospital Charge Code	8123863
Hospital Revenue Code	430
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$128.04
Rate for Payer: Cash Price	$85.80
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$118.80
Rate for Payer: MDX Hawaii PPO	$128.04

guaiFEN-dextro 100-10 mg/5 mL 118ml [HHSC]

Facility

$19.63

Service Code	NDC 00904005300
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$19.04
Rate for Payer: AlohaCare Medicaid	$9.81
Rate for Payer: AlohaCare Medicare	$9.81
Rate for Payer: Cash Price	$12.76
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Hawaii Medical Service Association Medicare	$9.81
Rate for Payer: Hawaii Western Management Group Commercial	$18.65
Rate for Payer: Health Management Network Commercial	$16.69
Rate for Payer: Humana Medicare	$9.81
Rate for Payer: Kaiser Permanente Commercial	$17.67
Rate for Payer: Kaiser Permanente Medicaid	$10.01
Rate for Payer: Kaiser Permanente Medicare	$9.81
Rate for Payer: MDX Hawaii PPO	$19.04
Rate for Payer: Ohana Health Plan Medicaid	$9.81
Rate for Payer: Ohana Health Plan Medicare	$9.81
Rate for Payer: UnitedHealthcare Medicaid	$11.78
Rate for Payer: UnitedHealthcare Medicare	$9.81
Rate for Payer: University Health Alliance Commercial	$14.31

guaiFEN-dextro 100-10 mg/5 mL 118ml [HHSC]

Facility

$5.61

Service Code	NDC 57896066116
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$5.44
Rate for Payer: AlohaCare Medicaid	$2.81
Rate for Payer: AlohaCare Medicare	$2.81
Rate for Payer: Cash Price	$3.65
Rate for Payer: Devoted Health Medicare	$3.09
Rate for Payer: Hawaii Medical Service Association Medicare	$2.81
Rate for Payer: Hawaii Western Management Group Commercial	$5.33
Rate for Payer: Health Management Network Commercial	$4.77
Rate for Payer: Humana Medicare	$2.81
Rate for Payer: Kaiser Permanente Commercial	$5.05
Rate for Payer: Kaiser Permanente Medicaid	$2.86
Rate for Payer: Kaiser Permanente Medicare	$2.81
Rate for Payer: MDX Hawaii PPO	$5.44
Rate for Payer: Ohana Health Plan Medicaid	$2.81
Rate for Payer: Ohana Health Plan Medicare	$2.81
Rate for Payer: UnitedHealthcare Medicaid	$3.37
Rate for Payer: UnitedHealthcare Medicare	$2.81
Rate for Payer: University Health Alliance Commercial	$4.09

guaiFEN-dextro 100-10 mg/5 mL 118ml [HHSC]

Facility

$5.61

Service Code	NDC 57896066116
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$5.44
Rate for Payer: Cash Price	$3.65
Rate for Payer: Health Management Network Commercial	$4.77
Rate for Payer: Kaiser Permanente Commercial	$5.05
Rate for Payer: MDX Hawaii PPO	$5.44

guaiFEN-dextro 100-10 mg/5 mL 118ml [HHSC]

Facility

$19.63

Service Code	NDC 00904005300
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$16.69
Max. Negotiated Rate	$19.04
Rate for Payer: Cash Price	$12.76
Rate for Payer: Health Management Network Commercial	$16.69
Rate for Payer: Kaiser Permanente Commercial	$17.67
Rate for Payer: MDX Hawaii PPO	$19.04

guaiFEN-dextro 100-10 mg/5 mL 118ml [HHSC]

Facility

$12.13

Service Code	NDC 71399100408
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$6.07
Max. Negotiated Rate	$11.77
Rate for Payer: AlohaCare Medicaid	$6.07
Rate for Payer: AlohaCare Medicare	$6.07
Rate for Payer: Cash Price	$7.88
Rate for Payer: Devoted Health Medicare	$6.67
Rate for Payer: Hawaii Medical Service Association Medicare	$6.07
Rate for Payer: Hawaii Western Management Group Commercial	$11.52
Rate for Payer: Health Management Network Commercial	$10.31
Rate for Payer: Humana Medicare	$6.07
Rate for Payer: Kaiser Permanente Commercial	$10.92
Rate for Payer: Kaiser Permanente Medicaid	$6.19
Rate for Payer: Kaiser Permanente Medicare	$6.07
Rate for Payer: MDX Hawaii PPO	$11.77
Rate for Payer: Ohana Health Plan Medicaid	$6.07
Rate for Payer: Ohana Health Plan Medicare	$6.07
Rate for Payer: UnitedHealthcare Medicaid	$7.28
Rate for Payer: UnitedHealthcare Medicare	$6.07
Rate for Payer: University Health Alliance Commercial	$8.84

guaiFEN-dextro 100-10 mg/5 mL 118ml [HHSC]

Facility

$8.11

Service Code	NDC 71399002606
Hospital Charge Code	2500227
Hospital Revenue Code	250
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$7.87
Rate for Payer: AlohaCare Medicaid	$4.05
Rate for Payer: AlohaCare Medicare	$4.05
Rate for Payer: Cash Price	$5.27
Rate for Payer: Devoted Health Medicare	$4.46
Rate for Payer: Hawaii Medical Service Association Medicare	$4.05
Rate for Payer: Hawaii Western Management Group Commercial	$7.70
Rate for Payer: Health Management Network Commercial	$6.89
Rate for Payer: Humana Medicare	$4.05
Rate for Payer: Kaiser Permanente Commercial	$7.30
Rate for Payer: Kaiser Permanente Medicaid	$4.14
Rate for Payer: Kaiser Permanente Medicare	$4.05
Rate for Payer: MDX Hawaii PPO	$7.87
Rate for Payer: Ohana Health Plan Medicaid	$4.05
Rate for Payer: Ohana Health Plan Medicare	$4.05
Rate for Payer: UnitedHealthcare Medicaid	$4.87
Rate for Payer: UnitedHealthcare Medicare	$4.05
Rate for Payer: University Health Alliance Commercial	$5.91

Know your out-of-pocket cost for care.

All Charges