Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

hepatitis B immune globulin (ADULT) 5 mL vial [HHSC]

Facility

$1,923.28

Service Code	NDC 59730420301
Hospital Charge Code	2500381
Hospital Revenue Code	250
Min. Negotiated Rate	$1,634.79
Max. Negotiated Rate	$1,865.58
Rate for Payer: Cash Price	$1,250.13
Rate for Payer: Health Management Network Commercial	$1,634.79
Rate for Payer: Kaiser Permanente Commercial	$1,730.95
Rate for Payer: MDX Hawaii PPO	$1,865.58

hepatitis B immune globulin (ADULT) 5 mL vial [HHSC]

Facility

$2,021.47

Service Code	NDC 69800420301
Hospital Charge Code	2500381
Hospital Revenue Code	250
Min. Negotiated Rate	$1,718.25
Max. Negotiated Rate	$1,960.83
Rate for Payer: Cash Price	$1,313.96
Rate for Payer: Health Management Network Commercial	$1,718.25
Rate for Payer: Kaiser Permanente Commercial	$1,819.32
Rate for Payer: MDX Hawaii PPO	$1,960.83

hepatitis B immune globulin (ADULT) 5 mL vial [HHSC]

Facility

$1,923.28

Service Code	NDC 59730420301
Hospital Charge Code	2500381
Hospital Revenue Code	250
Min. Negotiated Rate	$961.64
Max. Negotiated Rate	$1,865.58
Rate for Payer: AlohaCare Medicaid	$961.64
Rate for Payer: AlohaCare Medicare	$961.64
Rate for Payer: Cash Price	$1,250.13
Rate for Payer: Devoted Health Medicare	$1,057.80
Rate for Payer: Hawaii Medical Service Association Medicare	$961.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.12
Rate for Payer: Health Management Network Commercial	$1,634.79
Rate for Payer: Humana Medicare	$961.64
Rate for Payer: Kaiser Permanente Commercial	$1,730.95
Rate for Payer: Kaiser Permanente Medicaid	$980.87
Rate for Payer: Kaiser Permanente Medicare	$961.64
Rate for Payer: MDX Hawaii PPO	$1,865.58
Rate for Payer: Ohana Health Plan Medicaid	$961.64
Rate for Payer: Ohana Health Plan Medicare	$961.64
Rate for Payer: UnitedHealthcare Medicaid	$1,153.97
Rate for Payer: UnitedHealthcare Medicare	$961.64
Rate for Payer: University Health Alliance Commercial	$1,401.88

Hepatitis B Surface Antibody FSI

Facility

$127.00

Service Code	HCPCS 86706
Hospital Charge Code	8117947
Hospital Revenue Code	302
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Hepatitis B Surface Antibody FSI

Facility

$127.00

Service Code	HCPCS 86706
Hospital Charge Code	8117947
Hospital Revenue Code	302
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$14.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13.43
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$10.74
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$14.84
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$27.77

Hepatitis B Surface Antigen FSI

Facility

$147.00

Service Code	HCPCS 87340
Hospital Charge Code	8117948
Hospital Revenue Code	306
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$14.27
Rate for Payer: Hawaii Medical Service Association Commercial	$12.91
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.98
Rate for Payer: Hawaii Western Management Group Commercial	$10.33
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$26.70

Hepatitis B Surface Antigen FSI

Facility

$147.00

Service Code	HCPCS 87340
Hospital Charge Code	8117948
Hospital Revenue Code	306
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

Hepatitis C Ab by CIA FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	10378951
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: MDX Hawaii PPO	$158.11

Hepatitis C Ab by CIA FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	10378951
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association ABD	$19.73
Rate for Payer: Hawaii Medical Service Association Commercial	$17.84
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.27
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicaid	$19.73
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$36.89

Hepatitis C Antibody FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8117951
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association ABD	$19.73
Rate for Payer: Hawaii Medical Service Association Commercial	$17.84
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.27
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicaid	$19.73
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$36.89

Hepatitis C Antibody FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8117951
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: MDX Hawaii PPO	$158.11

Hepatitis C Genotype FSI

Facility

$2,876.00

Service Code	HCPCS 87902
Hospital Charge Code	8404559
Hospital Revenue Code	306
Min. Negotiated Rate	$2,444.60
Max. Negotiated Rate	$2,789.72
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: MDX Hawaii PPO	$2,789.72

Hepatitis C Genotype FSI

Facility

$2,876.00

Service Code	HCPCS 87902
Hospital Charge Code	8404559
Hospital Revenue Code	306
Min. Negotiated Rate	$256.16
Max. Negotiated Rate	$2,789.72
Rate for Payer: AlohaCare Medicaid	$1,438.00
Rate for Payer: AlohaCare Medicare	$1,438.00
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Devoted Health Medicare	$1,581.80
Rate for Payer: Hawaii Medical Service Association ABD	$256.16
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Medicare	$1,438.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$355.58
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Humana Medicare	$1,438.00
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: Kaiser Permanente Medicaid	$1,466.76
Rate for Payer: Kaiser Permanente Medicare	$1,438.00
Rate for Payer: MDX Hawaii PPO	$2,789.72
Rate for Payer: Ohana Health Plan Medicaid	$1,438.00
Rate for Payer: Ohana Health Plan Medicare	$1,438.00
Rate for Payer: UnitedHealthcare Medicaid	$256.16
Rate for Payer: UnitedHealthcare Medicare	$1,438.00
Rate for Payer: University Health Alliance Commercial	$665.43

Hepatitis C HCV Quant Rfx Genotype FSI

Facility

$478.00

Service Code	HCPCS 87522
Hospital Charge Code	8228882
Hospital Revenue Code	306
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$463.66
Rate for Payer: AlohaCare Medicaid	$239.00
Rate for Payer: AlohaCare Medicare	$239.00
Rate for Payer: Cash Price	$310.70
Rate for Payer: Cash Price	$310.70
Rate for Payer: Devoted Health Medicare	$262.90
Rate for Payer: Hawaii Medical Service Association ABD	$59.20
Rate for Payer: Hawaii Medical Service Association Commercial	$53.55
Rate for Payer: Hawaii Medical Service Association Medicare	$239.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$62.16
Rate for Payer: Hawaii Western Management Group Commercial	$42.84
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Humana Medicare	$239.00
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: Kaiser Permanente Medicaid	$243.78
Rate for Payer: Kaiser Permanente Medicare	$239.00
Rate for Payer: MDX Hawaii PPO	$463.66
Rate for Payer: Ohana Health Plan Medicaid	$239.00
Rate for Payer: Ohana Health Plan Medicare	$239.00
Rate for Payer: UnitedHealthcare Medicaid	$59.20
Rate for Payer: UnitedHealthcare Medicare	$239.00
Rate for Payer: University Health Alliance Commercial	$110.72

Hepatitis C HCV Quant Rfx Genotype FSI

Facility

$478.00

Service Code	HCPCS 87522
Hospital Charge Code	8228882
Hospital Revenue Code	306
Min. Negotiated Rate	$406.30
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$310.70
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: MDX Hawaii PPO	$463.66

Hepatitis C HCV RNA PCR Quantitative FSI

Facility

$478.00

Service Code	HCPCS 87522
Hospital Charge Code	8117952
Hospital Revenue Code	306
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$463.66
Rate for Payer: AlohaCare Medicaid	$239.00
Rate for Payer: AlohaCare Medicare	$239.00
Rate for Payer: Cash Price	$310.70
Rate for Payer: Cash Price	$310.70
Rate for Payer: Devoted Health Medicare	$262.90
Rate for Payer: Hawaii Medical Service Association ABD	$59.20
Rate for Payer: Hawaii Medical Service Association Commercial	$53.55
Rate for Payer: Hawaii Medical Service Association Medicare	$239.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$62.16
Rate for Payer: Hawaii Western Management Group Commercial	$42.84
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Humana Medicare	$239.00
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: Kaiser Permanente Medicaid	$243.78
Rate for Payer: Kaiser Permanente Medicare	$239.00
Rate for Payer: MDX Hawaii PPO	$463.66
Rate for Payer: Ohana Health Plan Medicaid	$239.00
Rate for Payer: Ohana Health Plan Medicare	$239.00
Rate for Payer: UnitedHealthcare Medicaid	$59.20
Rate for Payer: UnitedHealthcare Medicare	$239.00
Rate for Payer: University Health Alliance Commercial	$110.72

Hepatitis C HCV RNA PCR Quantitative FSI

Facility

$478.00

Service Code	HCPCS 87522
Hospital Charge Code	8117952
Hospital Revenue Code	306
Min. Negotiated Rate	$406.30
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$310.70
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: MDX Hawaii PPO	$463.66

Hepatitis C Virus Genotype FSI

Facility

$2,876.00

Service Code	HCPCS 87902
Hospital Charge Code	8117953
Hospital Revenue Code	306
Min. Negotiated Rate	$256.16
Max. Negotiated Rate	$2,789.72
Rate for Payer: AlohaCare Medicaid	$1,438.00
Rate for Payer: AlohaCare Medicare	$1,438.00
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Devoted Health Medicare	$1,581.80
Rate for Payer: Hawaii Medical Service Association ABD	$256.16
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Medicare	$1,438.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$355.58
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Humana Medicare	$1,438.00
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: Kaiser Permanente Medicaid	$1,466.76
Rate for Payer: Kaiser Permanente Medicare	$1,438.00
Rate for Payer: MDX Hawaii PPO	$2,789.72
Rate for Payer: Ohana Health Plan Medicaid	$1,438.00
Rate for Payer: Ohana Health Plan Medicare	$1,438.00
Rate for Payer: UnitedHealthcare Medicaid	$256.16
Rate for Payer: UnitedHealthcare Medicare	$1,438.00
Rate for Payer: University Health Alliance Commercial	$665.43

Hepatitis C Virus Genotype FSI

Facility

$2,876.00

Service Code	HCPCS 87902
Hospital Charge Code	8117953
Hospital Revenue Code	306
Min. Negotiated Rate	$2,444.60
Max. Negotiated Rate	$2,789.72
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: MDX Hawaii PPO	$2,789.72

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC

Facility

$65,464.92

Service Code	MSDRG 421
Min. Negotiated Rate	$65,464.92
Max. Negotiated Rate	$65,464.92
Rate for Payer: Hawaii Medical Service Association Commercial	$65,464.92

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC

Facility

$65,464.92

Service Code	MSDRG 420
Min. Negotiated Rate	$65,464.92
Max. Negotiated Rate	$65,464.92
Rate for Payer: Hawaii Medical Service Association Commercial	$65,464.92

HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC

Facility

$58,093.60

Service Code	MSDRG 422
Min. Negotiated Rate	$58,093.60
Max. Negotiated Rate	$58,093.60
Rate for Payer: Hawaii Medical Service Association Commercial	$58,093.60

Hep C Ab Rfx Quant FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8228880
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association ABD	$19.73
Rate for Payer: Hawaii Medical Service Association Commercial	$17.84
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.27
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicaid	$19.73
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$36.89

Hep C Ab Rfx Quant FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8228880
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: MDX Hawaii PPO	$158.11

Hep C Ab Rfx Quant, Rfx Genotype FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8228881
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association ABD	$19.73
Rate for Payer: Hawaii Medical Service Association Commercial	$17.84
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.27
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicaid	$19.73
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$36.89

Know your out-of-pocket cost for care.

All Charges