Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Iron Profile, Includes TIBC, Percent Saturation FSI

Facility

$128.00

Service Code	HCPCS 83550
Hospital Charge Code	8117976
Hospital Revenue Code	301
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$124.16
Rate for Payer: AlohaCare Medicaid	$64.00
Rate for Payer: AlohaCare Medicare	$64.00
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$70.40
Rate for Payer: Hawaii Medical Service Association ABD	$12.08
Rate for Payer: Hawaii Medical Service Association Commercial	$10.93
Rate for Payer: Hawaii Medical Service Association Medicare	$64.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.68
Rate for Payer: Hawaii Western Management Group Commercial	$8.74
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Humana Medicare	$64.00
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: Kaiser Permanente Medicare	$64.00
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: Ohana Health Plan Medicaid	$64.00
Rate for Payer: Ohana Health Plan Medicare	$64.00
Rate for Payer: UnitedHealthcare Medicaid	$12.08
Rate for Payer: UnitedHealthcare Medicare	$64.00
Rate for Payer: University Health Alliance Commercial	$22.59

Iron Profile, Includes TIBC, Percent Saturation FSI

Facility

$128.00

Service Code	HCPCS 83550
Hospital Charge Code	8117976
Hospital Revenue Code	301
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: MDX Hawaii PPO	$124.16

IRRIGATION .25% ACETIC ACID 1000ML CONTAINER

Facility

$78.00

Hospital Charge Code	8266639
Hospital Revenue Code	250
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

IRRIGATION .25% ACETIC ACID 1000ML CONTAINER

Facility

$78.00

Hospital Charge Code	8266639
Hospital Revenue Code	250
Min. Negotiated Rate	$39.00
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$74.10
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$46.80
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$56.85

IRRIGATION .9% NACL 1000ML

Facility

$12.00

Hospital Charge Code	8266621
Hospital Revenue Code	270
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

IRRIGATION .9% NACL 1000ML

Facility

$12.00

Hospital Charge Code	8266621
Hospital Revenue Code	270
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

IRRIGATION .9% NACL 2000ML

Facility

$17.00

Hospital Charge Code	8266622
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

IRRIGATION .9% NACL 2000ML

Facility

$17.00

Hospital Charge Code	8266622
Hospital Revenue Code	270
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$8.50
Rate for Payer: Cash Price	$11.05
Rate for Payer: Devoted Health Medicare	$9.35
Rate for Payer: Hawaii Medical Service Association Medicare	$8.50
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$8.50
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$8.50
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$8.50
Rate for Payer: Ohana Health Plan Medicare	$8.50
Rate for Payer: UnitedHealthcare Medicare	$8.50
Rate for Payer: University Health Alliance Commercial	$12.39

IRRIGATION .9% NACL 3000ML BAG

Facility

$66.00

Hospital Charge Code	8266581
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

IRRIGATION .9% NACL 3000ML BAG

Facility

$66.00

Hospital Charge Code	8266581
Hospital Revenue Code	270
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$48.11

IRRIGATION .9% NACL 500ML CONTAINER

Facility

$12.00

Hospital Charge Code	8266421
Hospital Revenue Code	272
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

IRRIGATION .9% NACL 500ML CONTAINER

Facility

$12.00

Hospital Charge Code	8266421
Hospital Revenue Code	272
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$8.75

IRRIGATION STERILE WATER 1000ML

Facility

$24.00

Hospital Charge Code	8266619
Hospital Revenue Code	270
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$17.49

IRRIGATION STERILE WATER 1000ML

Facility

$24.00

Hospital Charge Code	8266619
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

IRRIGATION STERILE WATER 2000ML (PLEASE ORDER CDM 670 - 2000ML IRRIGATION BAG)

Facility

$13.00

Hospital Charge Code	8266620
Hospital Revenue Code	270
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$8.45
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: MDX Hawaii PPO	$12.61

IRRIGATION STERILE WATER 2000ML (PLEASE ORDER CDM 670 - 2000ML IRRIGATION BAG)

Facility

$13.00

Hospital Charge Code	8266620
Hospital Revenue Code	270
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$12.61
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.45
Rate for Payer: Devoted Health Medicare	$7.15
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.70
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

IRRIGATION STERILE WATER 500ML CONTAINER

Facility

$20.00

Hospital Charge Code	8266401
Hospital Revenue Code	270
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$19.40
Rate for Payer: AlohaCare Medicaid	$10.00
Rate for Payer: AlohaCare Medicare	$10.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Devoted Health Medicare	$11.00
Rate for Payer: Hawaii Medical Service Association Medicare	$10.00
Rate for Payer: Hawaii Western Management Group Commercial	$19.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Humana Medicare	$10.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: Kaiser Permanente Medicaid	$10.20
Rate for Payer: Kaiser Permanente Medicare	$10.00
Rate for Payer: MDX Hawaii PPO	$19.40
Rate for Payer: Ohana Health Plan Medicaid	$10.00
Rate for Payer: Ohana Health Plan Medicare	$10.00
Rate for Payer: UnitedHealthcare Medicare	$10.00
Rate for Payer: University Health Alliance Commercial	$14.58

IRRIGATION STERILE WATER 500ML CONTAINER

Facility

$20.00

Hospital Charge Code	8266401
Hospital Revenue Code	270
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$13.00
Rate for Payer: Health Management Network Commercial	$17.00
Rate for Payer: Kaiser Permanente Commercial	$18.00
Rate for Payer: MDX Hawaii PPO	$19.40

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC

Facility

$50,817.09

Service Code	MSDRG 062
Min. Negotiated Rate	$50,817.09
Max. Negotiated Rate	$50,817.09
Rate for Payer: Hawaii Medical Service Association Commercial	$50,817.09

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC

Facility

$50,817.09

Service Code	MSDRG 061
Min. Negotiated Rate	$50,817.09
Max. Negotiated Rate	$50,817.09
Rate for Payer: Hawaii Medical Service Association Commercial	$50,817.09

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC

Facility

$50,817.09

Service Code	MSDRG 063
Min. Negotiated Rate	$50,817.09
Max. Negotiated Rate	$50,817.09
Rate for Payer: Hawaii Medical Service Association Commercial	$50,817.09

isoniazid 300 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00555007101
Hospital Charge Code	2500429
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

isoniazid 300 mg tablet [HHSC]

Facility

$26.02

Service Code	NDC 81665010830
Hospital Charge Code	2500429
Hospital Revenue Code	250
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$25.24
Rate for Payer: AlohaCare Medicaid	$13.01
Rate for Payer: AlohaCare Medicare	$13.01
Rate for Payer: Cash Price	$16.91
Rate for Payer: Devoted Health Medicare	$14.31
Rate for Payer: Hawaii Medical Service Association Medicare	$13.01
Rate for Payer: Hawaii Western Management Group Commercial	$24.72
Rate for Payer: Health Management Network Commercial	$22.12
Rate for Payer: Humana Medicare	$13.01
Rate for Payer: Kaiser Permanente Commercial	$23.42
Rate for Payer: Kaiser Permanente Medicaid	$13.27
Rate for Payer: Kaiser Permanente Medicare	$13.01
Rate for Payer: MDX Hawaii PPO	$25.24
Rate for Payer: Ohana Health Plan Medicaid	$13.01
Rate for Payer: Ohana Health Plan Medicare	$13.01
Rate for Payer: UnitedHealthcare Medicaid	$15.61
Rate for Payer: UnitedHealthcare Medicare	$13.01
Rate for Payer: University Health Alliance Commercial	$18.97

isoniazid 300 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00555007102
Hospital Charge Code	2500429
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

isoniazid 300 mg tablet [HHSC]

Facility

$26.02

Service Code	NDC 81665010830
Hospital Charge Code	2500429
Hospital Revenue Code	250
Min. Negotiated Rate	$22.12
Max. Negotiated Rate	$25.24
Rate for Payer: Cash Price	$16.91
Rate for Payer: Health Management Network Commercial	$22.12
Rate for Payer: Kaiser Permanente Commercial	$23.42
Rate for Payer: MDX Hawaii PPO	$25.24

Know your out-of-pocket cost for care.

All Charges